TUBERCULOUS EMPYEMA in ARTIFICIAL PNEUMOTHORAX … · 2020. 3. 10. · Thesis are, therefore, very...

TUBERCULOUS EMPYEMA

in

ARTIFICIAL PNEUMOTHORAX

T h e s is p r e se n te d f o r th e D egree

o f

M. D.

hy

F* A* Sm ith M. B. Ch»B* D*P*H»

ProQuest Number: 13870208

All rights reserved

INFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted.

In the unlikely event that the author did not send a com p le te manuscript and there are missing pages, these will be noted. Also, if material had to be removed,

a note will indicate the deletion.

uestProQuest 13870208

Published by ProQuest LLC(2019). Copyright of the Dissertation is held by the Author.

All rights reserved.This work is protected against unauthorized copying under Title 17, United States C ode

Microform Edition © ProQuest LLC.

ProQuest LLC.789 East Eisenhower Parkway

P.O. Box 1346 Ann Arbor, Ml 48106- 1346

TUBERCULOUS EMPYEMA IN ARTIFICIAL PNEUMOTHORAX

INTRODUCTION

T h i s t h e s i s c o n s i s t s o f a s t u d y o f 78 p a t i e n t s

i n whom e i g h t y one empyemata o c c u r r e d d u r i n g t r e a t m e n t

b y a r t i f i c i a l p n e u m o th o ra x . I n v e s t i g a t i o n c o v e r s

e t i o l o g y and t r e a t m e n t o f t h e s e e i g h t y one empyema t a

a n d s u r v i v a l o f t h e s e v e n t y e i g h t p a t i e n t s .

The o b j e c t s o f t h i s s t u d y were : -

1 . To a s c e r t a i n t h e p r i n c i p a l f a c t o r s r e s p o n s i b l e

f o r th e o c c u r r e n c e o f empyema i n t h e s e p a t i e n t s .

2 . To a s c e r t a i n s u r v i v a l f o l l o w i n g d i f f e r e n t

t y p e s o f t r e a t m e n t .

3 . To e v a l u a t e t r e a t m e n t .

4 . To c o n s i d e r how empyema c o u l d have b e e n

a v o i d e d i n t h e - t r e a tm e n t o f t h e s e c a s e s .

MATERIAL

E i g h t y - o n e empyemata o c c u r r e d i n s e v e n t y -

e i g h t p a t i e n t s , made up a s f o l l o w s

1 . F i f t y c a s e s ( 6 1 .7 $ ) o c c u r r e d i n p a t i e n t s

w i t h u n i l a t e r a l p n e u m o t h o r a c e s .

2 . T w e n t y - f i v e c a s e s ( 3 0 .9 $ ) o c c u r r e d a s u n i l a t e r a l

2 .

empyema t a i n b i l a t e r a l p n e u m o t h o r a c e s ,

3 , S ix c a s e s ( 7 . 4 / 0 o c c u r r e d i n t h r e e p a t i e n t s

w i t h b i l a t e r a l p n e u m o t h o r a c e s .

'The e i g h t y - o n e empyemata c o n s i d e r e d i n

t h i s t h e s i s c o m p r i s e d 8 3 . 5 $ o f t h e t o t a l number o f

n i n e t y - s e v e n empyemata w h ic h o c c u r r e d i n 1 ,4 4 8 c o n s e c u t

iv e p n e u m o th ra c e s i n d u c e d i n t h e C h e s h i r e J o i n t S a n a t o r i u m ,

M arke t D r a y t o n , S a l o p , d u r i n g a p e r i o d o f e i g h t y e a r s

f rom 1 s t J u l y , 1937 t o 3 0 t h J u n e , 1945.

Only c a s e s i n w h ic h t u b e r c l e b a c i l l i had

b e e n d e m o n s t r a t e d were i n c l u d e d i n t h e i n v e s t i g a t i o n ,

h en ce t h e r e j e c t i o n o f s i x t e e n o f th e t o t a l number o f

n i n e t y - s e v e n c a s e s .

T h i r t y - f i v e ( 4 3 .2 $ ) o f t h e e i g h t y - o n e empyemata

i n v e s t i g a t e d became s e c o n d a r i l y i n f e c t e d w i t h p y o g e n i c

o r g a n i s m s . These c a s e s a r e r e f e r r e d t o i n t h e t e x t

a s mixed Group 3 empyemata . The r e m a i n i n g f o r t y - s i x

c a s e s ( 5 6 .8 $ ) o f t h e t o t a l number o f e i g h t y - o n e a r e

t e r m e d " p u r e ” Group A empyemata .

T h i s s e r i e s o f a r t i f i c i a l p n e u m o th o ra c e s

i s a s e l e c t e d one i n so f a r a s

1 . The p e r i o d 1937 t o 1945 was c h o s e n f o r

s t u d y d e l i b e r a t e l y , t o a s c e r t a i n t h e i n c i d e n c e o f empyema

d u r i n g t h a t t i m e . The r e a s o n s w e r e , f i r s t l y , t h a t

i t was c o n s i d e r e d i n t h e l i g h t o f s u b s e q u e n t e x p e r i e n c e

t h a t a l a r g e number o f " b a d ” p n e u m o th o ra o e s were

in d u c e d i n t h e S a n a t o r iu m d u r i n g t h o s e y e a r s . By

t h e t e r m "bad" i s meant t h a t w h i l e r i s k s have o c c a s i o n

a l l y t o be t a k e n i n t h e c h o ic e o f p a t i e n t s t o be

t r e a t e d by p n e u m o th o ra x , t o o many p a t i e n t s known now t o be

u n s u i t a b l e f o r t h a t t y p e o f t r e a t m e n t were i n f a c t

t r e a t e d by a r t i f i c i a l p n eu m o th o ra x d u r i n g t h e p e r i o d

u n d e r r e v i e w . On t h e o t h e r h a n d , i t m us t be remembered

t h a t many p a t i e n t s i n c l u d e d i n t h i s s e r i e s who were known

a t t h e t im e t o be bad r i s k s f o r p n eu m o th o ra x t r e a t m e n t

were d e s t i n e d t o d i e more or l e s s q u i c k l y u n l e s s some

a t t e m p t were made t o a r r e s t t h e i r d i s e a s e ,

2 . A l l t h e p n e u m o th o ra c e s were in d u c e d i n one

I n s t i t u t i o n by t h e same team o f p h y s i c i a n s . Alm ost

a l l t h e a d h e s i o n s e c t i o n s by c l o s e d p n e u m o ly s i s were

p e r fo r m e d by one member o f t h e t e a m . He had e x t e n s i v e

e x p e r i e n c e o f t h e t r e a t m e n t o f pu lm o n ary t u b e r c u l o s i s

a n d i n p a r t i c u l a r o f t h e o p e r a t i o n o f i n t e r n a l c l o s e d

p n e u m o l y s i s .

F o l lo w -u p o f t h e p a t i e n t s u n d e r r e v i e w was

c o n s i d e r e d u n t i l 3 1 s t December 1949. Thus t h e l o n g e s t

p o s s i b l e p e r i o d o f s u r v i v a l was l l i y e a r s an d t h e

s h o r t e s t 3-| y e a r s .

C e r t a i n d i s a d v a n t a g e s a r i s e i n a r e l a t i v e l y

4 .

long p e r i o d f o l l o w - u p when c o n s i d e r i n g a d i s e a s e w i t h

a h i g h m o r t a l i t y r a t e s u c h a s t u b e r c u l o u s empyema. •

The f i r s t d i s a d v a n t a g e i s t h e need f o r

g r e a t e r d e p e n d en ce on r e c o r d s , and in p a r t i c u l a r on

t h e i r a c c u r a c y . More r e c e n t c a s e s o f f e r t h e

p o s s i b i l i t y and o p p o r t u n i t y a s was p r o v i d e d i n some

i n c l u d e d i n t h i s r e v i e w o f p e r s o n a l e x a m i n a t i o n o f t h e

p a t i e n t w i t h c o m p a r i so n o f o r i g i n a l and most r e c e n t

s k i a g r a m s .

The sec o n d d i s a d v a n t a g e o f a long p e r i o d f o l l o w -

up i s t h a t i t t e n d s t o i n c r e a s e t h e number o f c a s e s

coming i n t o t h e c a t e g o r y " l o s t s i g h t o f " : i n t h e 78

p a t i e n t s u n d e r r e v i e w , s i x ( 7 .7 $ ) were l o s t s i g h t o f .

Two o f t h e s e s i x p a t i e n t s were known t o be a l i v e a t

t h e end o f 1948 and wer*e i n f a c t " l o s t s i g h t o f" f o r

o n l y one y e a r . The r e c o r d s o f t h e o t h e r f o u r p a t i e n t s

had b e en l o s t o r d e s t r o y e d .

The t h i r d d i s a d v a n t a g e a p p l i e s t o a l l f o l l o w - u p

p r o c e d u r e s i n a s t u d y o f t r e a t m e n t o f t u b e r c u l o s i s

p a t i e n t s . T h c to r s s u c h a s t h e t e n d e n c y o f t h e d i s e a s e

t o s e l f - h e a l i n g , th e i n d i v i d u a l r e s i s t a n c e a n d tem p eram en t

o f p a t i e n t s , t h e i n f l u e n c e o f home, s o c i a l and w ork ing

e n v i r o n m e n t and o c c u p a t i o n m u s t ; i n a long t e r m f o l l o w - u p ,

have a b e a r i n g on t h e s u r v i v a l o f p a t i e n t s , and th e

l o n g e r t h e f o l l o w - u p th e g r e a t e r t h e e f f e c t o f t h e s e

5

o u t s i d e i n f l u e n c e s i s l i k e l y t o "be. Such inp o n r)e rah 1 e s

make i t a lm o s t i m p o s s i b l e t o s e t up v a l i d s t a n d a r d s f o r

t r e a t m e n t i n so p r o t e a n a d i s e a s e as p u lm o n ary

t u b e r c u l o s i s . On t h e o t h e r hand , t o o s h o r t a p e r i o d

o f f o l l o w - u p f a i l s t o c o v e r t h e whole d i s e a s e p r o c e s s

and t e n d s t o p u t t r e a t m e n t i n a p e r s p e c t i v e t o o f a l s e

t o p e r m i t o f any v a l i d c o n c l u s i o n s b e i n g drawn t h e r e f r o m .

S i m i l a r l y , t h e c h r o n i e i t y o f p u lm onary t u b e r c u l o s i s

r a i s e s t h e q u e s t i o n o f t h e minimum p e r i o d o f t im e f o r

w h ic h o b s e r v a t i o n i s n e c e s s a r y t o r e a c h r e a s o n a b l e and

s o u n d •c o n e l u s i o n s .

F i n a l l y , i t w i l l be a p p r e c i a t e d t h a t a s e r i e s

o f o n l y 78 c a s e s i s t o o s m a l l f o r e l a b o r a t e s t a t i s t i c a l

e v a l u a t i o n . Such s t a t i s t i c s as a r e i n c l u d e d i n t h i s

T h e s i s a r e , t h e r e f o r e , v e r y s im p le .

T h i s T h e s i s i s d i v i d e d i n t o f o u r p a r t s ,

a s f o l l o w s

P a r t 1 d e a l s w i t h t h e d e f i n i t i o n o f T u b e r c u l o u s

Empyema a s u n d e r s t o o d i n t h i s r e v i e w and w i t h t h e i n c i d e n c e

age and s e x d i s t r i b u t i o n i n t h e 78 p a t i e n t s b e i n g s t u d i e d .

P a r t 2 i s d e v o te d to E t i o l o g y .

P a r t 3 d e a l s w i t h T r e a t m e n t and R e s u l t s .

P a r t k- i s d e v o t e d t o D i s c u s s i o n and

C o n c l u s i o n s .

PART 1

The d e f i n i t i o n o f empyema i n a r t i f i c i a l

p n e u m o th o ra x a p p l i e d i n t h i s s e r i e s i s s i m i l a r t o

t h a t u s e d "by D i c k e y (19^1-3) > t h a t t h e e x u d a t e s h o u l d he

t u r b i d o r p u r u l e n t and t h a t t h e t u b e r c l e b a c i l l u s

have b e e n d e m o n s t r a t e d i n t h e a s p i r a t e d f l u i d , e i t h e r

on d i r e c t smear e x a m i n a t i o n , o r on c u l t u r e o r by

a n im a l i n o c u l a t i o n ,

INCIDENCE

The i n c i d e n c e o f empyema i n a r t i f i c i a l p n eum othora x

v a r i e s a c c o r d i n g t o t h e d e f i n i t i o n used* I n t h i s

s e r i e s t h e r e were a l t o g e t h e r n i n e t y - s e v e n empyemata

i n a t o t a l o f f o u r t e e n h u n d re d and f o r t y e i g h t

c o n s e c u t i v e p n e u m o th o ra c e s . A p p ly in g t h e d e f i n i t i o n

q u o te d above , s i x t e e n c a s e s (l6*5/u) were d i s c a r d e d

b e c a u s e t u b e r c l e b a c i l l i were n e v e r a t any t im e

d e m o n s t r a t e d i n t h e e x u d a t e .

The i n c i d e n c e o f empyema i n t h i s s e r i e s

o f p n eu m o th o ra ces i s , t h e r e f o r e , as shown i n T a b le I ,

TABLE I

I n c id e n c e o f Empyema in 1448 C o n se c u tiv e Pneum othoraces

A r t i f i c i a l Pneum othoraces

T ab le r e f e r s o n ly to ex u d a tes w hich p r o g r e sse d a t l e a s t

to th e l e v e l o f - t h e 5 th c o s t a l c a r t i l a g e or h ig h e r when

v iew ed on th e f lu o r o s c o p ic s c r e e n or on skiagram .

o r in th e c o s to -p h r e n ic a n g le a re n o t h e ld to be e f f u s io n

a s u n d ersto o d in t h i s s e r i e s . The v a s t m a jo r ity o f th e s e

sm a ll e f f u s io n s are tem porary and e v a n e sc e n t and o ccu r

in a l l pneumo th o r a c e s a t one tim e or ’a n o th er .

A l l e f f u s io n s o ccu rred w h ile p a t ie n t s

were in th e Sanatorium , b u t fo u r o f th e 81 empyemata

Humber1448

E f fu s io n s 3 8 3 (2 6 . 5$)

Ho E f fu s io n 1065 (7 3 . 6$)

P u ru len t E f fu s io n s (Hot a l l d e f in e d

a s empyemata)97 (6.7%)

H o n -p u ru len t E ffu s io n s

286 (19.8% )

Empyema t a (a c c o r d in g to d e f in i t i o n ) 81 ( 5.6%)

Group A (p ure) Group B46 (3.2%) 35 (2.4% )

(m ixed)

E f fu s io n in to pneum othorax in th e above

P u d d les o f f l u i d o v er th e diaphragm

o c c u r r e d i n p a t i e n t s a f t e r d i s c h a r g e f rom t h e

S a n a t o r iu m f o l l o w i n g s a t i s f a c t o r y , o r a p p a r e n t l y

s a t i s f a c t o r y , t r e a t m e n t o f t h e e f f u s i o n .

SSX AND AGS INC ID3NC:

3 .

7 .

78 P a t i e n t s ‘

The sex i n c i d e n c e was a s shown i n T a b l e s 2 and

The age i n c i d e n c e was a s shown i n T a b le s 4 t o

TABLS 2

Sex and Age I n c i d e n c e

78 P a t i e n t s '

Sex i n c i d e n c e w a s : - Ma le s 42

Pfemales 36

T o t a l 78

5 3 . 7 $

4 6 . 3 $

1 0 0 .0$Ma l e s 7° Serna le s % T o t a l

U n i l a t e r a l pneumot h o r a x and empyema 31 59 .6 19 2 4 . 4 50 6 4 .0

B i l a t e r a l pneumot h o r a c e s and u n i l a t e r a l empyema 9 11 .5 16

_<D•

CCV} 25 3 2 . 1

B i l a t e r a l pneumot h o r a c e s and b i l a t e r a l empyema 2 2 . 6 1 1.3 3 3 .9

T o t a l ............... 42 5 3 .7 36 46 .3 78 100.0-

9.

Group A and Group B G ase s

T h i r t y - f o u r o f t h e 78 p a t i e n t s (1+3-6%) had

t h e i r empyemata s e c o n d a r i l y i n f e c t e d . One p a t i e n t

w i t h b i l a t e r a l empyema had b o t h s i d e s o y o g e n i c a l l y

i n f e c t e d . Thus t h i r t y - f i v e o f t h e 81 empyemata f a l l

i n t o Group B, e q u i v a l e n t t o 1+3• 2% o f t h e t o t a l number

o f empyemata. F o r t y - f o u r (56.1+%) o f t h e 78

p a t i e n t s and f o r t y s i x ( 5 6 . 8%) o f t h e 81 empyemata*

f a l l i n t o Group A- p u r e t u b e r c u l o u s empyema. The

s e x i n c i d e n c e i n Group B c a s e s i s shown i n T a b le 3»

TABLE 3

Sex I n c i d e n c e - Group B - 3h P a t i e n t s .

Males F em ales

No. rrf/'O No. % T o t a l %

U n i l a t e r a l empyema i n u n i l a t e r a l pn eu m o th o ra x

i b h i , 2 8 2 3 .5 22 61+. 7

B i l a t e r a l pneum othorax u n i l a t e r a l empyema

B i l a t e r a l pneumot h o r a x and b i l a t e r a l

3 8 .8 6 1 7 .7 9 2 6 . 5

empyema 2 5 .9 1 2 . 9 3 8 . 8

T o t a l --------19 5 5 .9 15 d d . l 3k l o o . o

I n Group B,one o f t h e b i l a t e r a l empyema c a s e s ,

10

a man had b o t h empyemata s e c o n d a r i l y i n f e c t e d .

Thus 20 ( 5 7 .1 $ ) o f t h e t o t a l o f 35 s e c o n d a r i l y i n f e c t e d

p n e u m o th o ra c e s o c c u r r e d i n men, and 15 ( 4 2 .9 $ ) i n women.

Age d i s t r i b u t i o n i s shown i n T a b le 4 b e l o w .

TABL5 4

Age D i s t r i b u t i o n - 78 P a t i e n t s

Age d i s t r i b u t i o n on a d m i s s i o n was a s f o l l o w s : -

Age Group Ma l e s Fema le s To ta 1 | P e r c e n t

15-19 5 5 10 j 1 2 .8

2 0 -2 4 13 13 26 33 .3-

2 5 -2 9 6 8 14 1 7 .9

3 0 -3 4 9 7 16 2 0 .5

3 4 -3 9 • 5 2 7 9 . 0

io■‘sP 1 -1 2 2 . 6

45-49 2 0 2 2 . 6

50-54 1 0 1 1.3

Over 54 0 0 0

T o t a l . . . . . . 42 36 78 1 00 .0

NO.

OP

PATI

ENTS

11

TABLE 5

Combined Age & Sex D i s t r i b u t i o n

78 P a t i e n t s .

30

a ■ CDCM

1cm

| t o1 t o■c c

i ir~

1LG

CM OP I>r. t*r:

ACS CROUPS

50-5

4

12

TABLE 6

50 G ases o f Uni l a t e r a l Pneu m o th o r ax and -Empyema

Age D i s t r i b u t i o n on Admiss i o n

Age Group Males F em ales T o t a l %

15 -19 2 3 5 10

20-2U 8 5 13 26

25-29 6 h. 10 20

30-31+ 7 ii. 11 22

3 5 -3 9 h 2 6 12

l±0~L\b 1 1 2 h

1+5-U9 2 0 2 k

50-51; 1 0 1 2

Over 5U 0 0 0 0

Tot .a ls 31 19 50 100 ' j

13

TABLE J

25 Cas e s o f U n i l a t e r a l Empyema i n B i l a t e r a l P n e u m o th o rax

3_ O a s e s o f B i l a t e r a l Empyemk

Age D i s t r i b u t i on on A d m is s io n

Age Group Males F em ales T o t a l %

1 5 -1 9 3 2 5 1 7 .9

20-2U 5 x 8 x 13 L6. k

25-29 0 k h I k . 2

30-3U 2 3 5 17. 9

3 5 -3 9 1 X 0 1 3 .6

ipO—ipip 0 0 0

k 5 -k 9 0 0 0

50-5U 0 0 0

Over 5i| 0 0 0

T o t a l s . . . . . . 11 17 28 100. 0

x I n c l u d e s two c a s e s o f B i l a t e r a l empyema , one male

t h e o t h e r f e m a le .

X I n c l u d e s one c a s e o f B i l a t e r a l empyema.

T a b le s 6 and 7 show t h a t i n t h e 50 u n i l a t e r a l A. P.

c a s e s which d e v e l o p e d empyema ? 31 (6 0 ;o) were nia.les

14

and 19 (38%) were f e m a l e s .

I n t h e 28 b i l a t e r a l p n eum othorax c a s e s ,

on t h e o t h e r h a n d , t h e e x a c t r e v e r s e o c c u r r e d . Only

11 (39.3%) were m a le s a n d 17 (60,7%) were f e m a l e s .

Age d i s t r i b u t i o n showed th e g r e a t e s t number

i n b o t h u n i l a t e r a l and b i l a t e r a l , A.P* s . f e l l i n t o

t h e 2 0 -2 4 age g r o u p , w i t h t h e age g r o u p 3 0 -3 4 coming

s e c o n d .

81 Empyemata

44 (54.3%) o f t h e empyemata o c c u r r e d i n m ales

and 37 (45.7%) i n f e m a l e s .

The r i g h t and l e f t s i d e s were a f f e c t e d , a s

shown i n t h e T a b le b e l o w .

TABIAL8

Showing S ide o f Ches t a f f e c t e d i n 81 Empyemata .

Ma le s Ffemca le sR ig h t Le f t R ig h t L e f t

U n i l a t e r a l A .P , and empyema 15 16 7 12

B i l a t e r a l A .P , and u n i l a t e r a l empyema 4 5 4 12

B i l a t e r a l A .P , and b i l a t e r a l empyema 2 2 1 1

T o t a l .......... .. 21 23 12 25

15

Thus o f th e 44 empyemata w hich o ccu rred m

m a le s , 21 ( 4 7 .y>) o ccu rred on th e r ig h t s id e , and

23 { 52 . 3%) on th e l e f t .

Of 37 empyemata in f e m a le s , 12(32.4% ) occu rred ,

on th e r ig h t s id e , and 25(67.6% ) on th e l e f t s id e .

B oth s e x e s com bined showed a fr eq u en cy o f

R igh t s id e d empyemata . . . . . 33 c a s e s (40.7% )

L e ft s id e d empyemata . . . . . 48 c a s e s (59.3% )

C l a s s i f i c a t i o n o f C ases on A d m ission

C ases w ere c l a s s i f i e d on a d m iss io n and r e

c l a s s i f i e d on in d u c t io n o f pneum othorax a c c o r d in g to

th e M in is tr y o f H e a lth ’ s c l a s s i f i c a t i o n o f pulm onary

t u b e r c u lo s is .

TABLE 9

C l a s s i f i c a t i o n on A d m ission and on In d u c t io n o f A .P .

78 C ases

C l a s s i f i c a t i o n Min. o f H ea lth

On A d m ission On I n d u c t io n o f A. P.no . % No. %

R.A. 2 5 6 .4 1 1 .3R. A. 3 1 1 .3 0 0R.B. 2 56 7 1 .8 60 7 6 .9R.B. 3 16 2 0 .5 17 2 1 .8

T o ta l . 78 1 0 0 .0 78 1 0 0 .0

16

A l l f iv e c a s e s w h ich were c la s s e d a s R .A .

on a d m iss io n became R .B . some tim e d u r in g tr e a tm e n t ,

fo u r w ith in a few weeks from a d m is s io n .

TABLE) 10 - 50 C ases

C l a s s i f i c a t i o n o f 50 U n i la t e r a l A .P . and EmpyemaC ases on A dm ission

C l a s s i f i c a t i o n M in. o f H ea lth

On A d m ission On In d u c tio n o f A .P .No. % No. %

R .A .2 5 10 1 2

R .A .3 1 2 0 0

R.B .2 36 72 40 80

R.B .3 8 16 9 18

T o ta l ............... 50 100 50 100

TAB IE 11 - 28 Cases

C l a s s i f i c a t i o n o f 28 Cases ’ o f B i l a t e r a l Pneum othorax.25 C ases d ev e lo p ed U n i la t e r a l Empyema: 3 C ases B i l a t e r a l

C l a s s i f i c a t i o n Min. o f H ea lth

On A dm ission On In d u c tio n o f A .P .No. <9{0 No. %

R .A . 0 0 0 0

R.B .2 20 7 1 .4 20 7 1 .4

R.B .3 8 2 8 .6 8 2 8 .6

T o ta l ............... 28 1 0 0 .0 _ ..... .. ..... ....

28 10 0 .0

One o f th e b i l a t e r a l pneumothorax c a s e s w h ich

17

d e v e l o p e d b i l a t e r a l empyema was i n c a t e g o r y R . B . 2 .

The o t h e r two s i m i l a r c a s e s were i n c a t e g o r y R .B .3 .

fam ily h i s t o r y

T h i r t y - f i v e o f t h e 78 p a t i e n t s (44.9 .$) gave

a f a m i l y h i s t o r y o f pu lm onary t u b e r c u l o s i s . The

r e m a i n d e r , f o r t y - t h r e e p a t i e n t s ( 5 5 .1 $ ) had no

p r e v i o u s p o s i t i v e f a m i l y h i s t o r y .

C o n t a c t s -

Of t h e t o t a l number o f s e v e n t y - e i g h t c a s e s ,

n i n e t e e n ( 2 4 .3 $ ) were c o n t a c t s o f o t h e r c a s e s .

I e n e t h o f s t a y i n S a n a t o r iu m ----- ^ | ———---- ~ty— — ------- -1|--|-- | mi || ,

The l o n g e s t s t a y o f a p a t i e n t a f t e r empyema

d e v e l o p e d was 1 ,4 2 8 d a y s . The a v e r a g e s t a y was

541 d a y s .

PART 2

18

ETIOLOGY

1• P r e c e d i n g S e r o u s B f f u s i o n _

R a f f e r ty ( 1 9 U U ) s t a t e s t h a t empyema o c c u r s

a lm o s t i n v a r i a b l y a f t e r many weeks o r months o f s e r o u s

e f f u s i o n . Change f rom s e r o u s e f f u s i o n t o f r a n k pus

o c c u r s a t a v a r y i n g i n t e r v a l a c c o r d i n g t o t h e s e v e r i t y

o f t h e p l e u r a l i n f e c t i o n , ( K e e n s and R i g d e n , 1 9 k 5 ) *

P r e l i m i n a r y e f f u s i o n i n t h i s s e r i e s was as

shown i n T a b le 12 be low .

TABLE 12 81 Empyemata...... . .-'- .v ..rho .

o f A. Ps %P r e c e d e d by c l e a r e f f u s i o n 56 69*1

P r e c e d e d by h a e m o th o ra x 3 3*7

Pus on o c c a s i o n o f f i r s t a s p i r a t i o n 22 27. 2

T o t a l 81 1 0 0 .0

Of t h e f i f t y - s i x c a s e s p r e c e d e d b y s e r o u s

e f f u s i o n , a t o t a l o f t w e n t y - t h r e e (U-l. 1%) became t u r b i d

by t h e t im e o f t h e se co n d a s p i r a t i o n and r e m a in e d

t u r b i d t h r o u g h o u t t h e c o u r s e o f t r e a t m e n t . The r e m a i n i n g

t h i r t y - t h r e e c a s e s ( 5 8 .9 b ) p r o g r e s s e d t o f r a n k p u s .

The i n t e r v a l which e l a p s e d b e tw e e n t h e f i r s t

a s p i r a t i o n o f s e r o u s f l u i d and t h e f i r s t a s p i r a t i o n o f

pus i n t h e s e t h i r t y —t h r e e c a s e s i s shown i n T a b le 13*

19

TABL5 15

55 Cases o f Serous B f f u s io n .

I n t e r v a l in w eeks from a s p ir a t io n o f se ro u s f l u i d t o a s p ir a t io n o f p u s .

I n t e r v a lWeeks

No. o f Gases *

2 - 4 7 2 1 .3

5 - 8 9 2 7 .3

9 - 1 2 4 1 2 ,1

1 3 - 1 6 5 1 5 .1

17 - 20 1 3 .0

21 - 24 3 9 .1

25 - 28 1 3 .0

29 - 32 0 0

33 - 36 1 3 .0

Not known | 2 6 .1

T o ta l . « • • • • .................. 33 1 0 0 .0

Of the 33 c a s e s in whom sero u s e f f u s i o n

p r o g r esse d to p u s, a t o t a l o f 16 '(4 8 .6 # ) had

d ev e lo p ed pus w ith in 8 weeks and 25 c a se s (7 5 .8 # )

w ith in 16 weeks from th e o c c a s io n o f th e i n i t i a l

a s p ir a t io n o f se ro u s f l u i d .

In two c a s e s th e in t e r v a l was n o t known.

These c a se s had had ser o u s e f f u s io n w h ile in th e

Sanatorium , had been d isc h a rg ed w ith a d ry p le u r a l

20

s p a c e , b u t were r e - a d m i t t e d a f t e r i n t e r v a l s o f

s i x months and 7 i months r e s p e c t i v e l y w i t h pus

i n t h e p neum othorax s p a c e .

T h re e Haemothorax Cases .

T h re e c a s e s d e v e l o p e d h aem o th o ra x a f t e r

a d h e s i o n s e c t i o n . Pus d e v e l o p e d i n s i x , e l e v e n

a n d e i g h t e e n weeks r e s p e c t i v e l y from t h e t im e o f

h a e m o t h o r a x .

2 . I n f e c t i o n .

The t u b e r c l e b a c i l l u s was d e m o n s t r a t e d i n

t h e f l u i d a s p i r a t e d f rom a l l c a s e s i n t h i s s e r i e s .

T h i s f i n d i n g e s t a b l i s h e d t h e p r i n c i p a l e t i o l o g i c a l

cau se o f i n f e c t i o n .

C u l t u r e o f a s p i r a t e d m a t e r i a l was r o u t i n e

p r o c e d u r e a f t e r d i r e c t smear e x a m i n a t i o n , w h e t h e r

t h e l a t t e r was p o s i t i v e o r n o t . G u inea p i g i n o c u l a t

i o n was u s e d i n two c a s e s i n w h ic h c u l t u r e was n e g a t

i v e .

D e m o n s t r a t i o n o f t h e t u b e r c l e b a c i l l u s i n

t h e e i g h t y - o n e c a s e s was a s shown i n T a b le 14.

21

TABLE 14 - 81 C ases

D em on stra tion o f T u b ercle B a c i l l i in P le u r a l E x u d a te .

No. $

P le u r a l exu d ate p o s i t i v e on d i r e c t smear and c u ltu r e 57 7 0 .4

N eg a tiv e d ir e c t sm ear, p o s i t i v e on c u ltu r e 22 2 7 .2

N eg a tiv e c u ltu r e and smear b u t p o s i t i v e on g u in e a -p ig in o c u la t io n 2 2 .4

T o ta l 81 1 0 0 .0

Secondary P yogen ic I n f e c t io n -

T h ir ty - fo u r p a t ie n t s (4 3 .6 $ ) had t h e i r

empyemata s e c o n d a r ily in fe c te d * One p a t ie n t w ith

b i l a t e r a l empyemata had b o th s id e s s e c o n d a r ily in f e c t e d .

Thus t h i r t y - f i v e (4 3 .2 $ ) o f 81 empyemata f a l l in to

th e p y o g e n ic a l ly in f e c t e d Group B.

Secondary In fec tin g ; Organisms -

T w enty-n ine (8 2 .8 $ ) o f the 35 Group B empyemata

were in f e c t e d w ith S ta p h y lo co ccu s Aureus and S ta p h y lo co ccu s

A lbus •

Four c a s e s (1 1 .4 $ ) became in f e c t e d w ith

b o th s ta p h y lo c o c c i and s t r e p t o c o c c i some tim e during

tr e a tm e n t . One ca se (2 .4 $ ) became in fe c te d w ith

s ta p h y lo c o c c i , s t r e p t o c o c c i and pneum ococci, and one

o th er case w ith B . P r o te u s .

22

TABLT 15

'Causes o f Pyo g en ic I n f e c t i o n .

The c a u s e s o f s e c o n d a r y i n f e c t i o n were a s f o l l o w s :

No. o f Cases o f

Pneumot h o ra x %

B r o n c h o - p l e u r a l f i s t u l a e 18 5 1 . 4

I n f e c t e d d u r i n g t r e a t m e n t i n S a n a t o r iu m a s p i r a t i o n 15 4 2 .9

I n f e c t e d d u r i n g t r e a t m e n t a s o u t - p a t i e n t s and r e - a d m i t t e d w i t h s e c o n d a r y i n f e c t i o n 2 5 . 7

T o t a l 35 1 0 0 .0

P l e u r o - c u t a n e o u s S i n u s e s -

T w enty - tw o p a t i e n t s g o t p l e u r o - c u t a n e o u s

s i n u s e s , and one p a t i e n t d e v e lo p e d t u b e r c u l o u s n o d u le s

i n t h e s k i n a s t h e r e s u l t o f t r e a t m e n t . A l l 22 c a s e s o f

p l e u r o - c u t a n e o u s s i n u s , r e p r e s e n t i n g 2 7 . 2 % o f t h e em pyem ata ,

became s e c o n d a r i l y i n f e c t e d . F u r t h e r d e t a i l s o f t h e

t r e a t m e n t w h ic h r e s u l t e d i n t h e s e p a t i e n t s d e v e l o p i n g

s i n u s e s , and o f t h e i r c o n d i t i o n on d i s c h a r g e , w i l l

be g i v e n i n t h e s e c t i o n d e v o t e d t o T r e a t m e n t an d R e s u l t s .

3 . C l a s s i f i c a t i o n o f D i s e a s e on Adrnissi on .

I t was d e c i d e d t o c l a s s i f y t h e t y p e s o f

d i s e a s e i n t h e p r e s e n t s e r i e s o f p a t i e n t s i n t o two g r o u p s ,

25

a p a rt from th e c l a s s i f i c a t i o n g iv e n on page 1 5 , w h ich

i s th a t o f th e M in is tr y o f H e a lth .

These two groups w e r e ; -

1 . C l a s s i f i c a t i o n a c c o r d in g t o t h a t a c c e p te d

by th e N a t io n a l T u b e r c u lo s is A s s o c ia t io n o f Am erica

a s m o d ified by S a lk in and Cadden (1 9 4 1 ) .

2 . C l a s s i f i c a t i o n a s a c c u r a t e ly a s r a d i o l o g i c a l

and c l i n i c a l f in d in g s would a llo w in to th e fo u r

groups su g g e s te d by R a f fe r ty (1 9 4 4 ) a s b e in g un

s u i t a b le fo r pneum othorax tr e a tm e n t .

D i f f i c u l t y was en co u n tered in c l a s s i f y i n g

c a se s in t o R a f fe r ty ! s G-roup IV, th a t i s , p a t ie n t s

w ith t u b e r c u lo s is o f a m ajor b ro n ch u s, f o r th e r e a so n

th a t r o u t in e b ron ch oscop y was not p r a c t is e d in th e

Sanatorium d u rin g the p er io d under r e v ie w . I n s te a d ,

i t was d ec id ed t o assume th a t p a t ie n t s in whom

com plete a t e l e c t a s i s o f th e lung occu rred d u rin g

pneumothorax trea tm en t must have b e e n s u f f e r in g from

se v e r e en d o b ro n ch ia l t u b e r c u lo s is a t th e tim e th e

pneumothorax was in d u ced . T h is a ssu m p tio n i s

b a sed on e x p e r ie n c e o f c a s e s in su b seq u en t y e a r s ,

fo r in e v e r y ca se in w hich com plete a t e l e c t a s i s o c cu r r ed ,

en d o b ro n ch ia l d is e a s e o f g r e a te r or l e s s e r s e v e r i t y ,

b u t a lw yys a f f e c t i n g a m ajor b ro n ch u s, was found a t

b ro n ch o sco p y .

24

T a b le 16 shows th e c l a s s i f i c a t i o n acco rd

in g to S a lk in and Cadden (1 9 4 1 ) . No c a se came in to

th e Group I c a te g o r y o f m inim al d i s e a s e .

TABLE 16, 78 C ases

C l a s s i f i c a t i o n (S a lk in and Cadden)

GroupNo.

T o ta lC l a s s i f i c a t io n

Sub-GroupNo.

Onelu n g

d is e a s e

O therlu n g

d is e a s e

No. o f C ases %

I I M oderate 5 mod. min. 9 11. 5d is e a s e 6 mod. mod. 15 19. 2

I I I Ear advanced 7 mod. mm. 3 3. 8d is e a s e 8 mod. mod. 14 1 7 .9

9 f a r c le a r 2 2 .510 f a r min. 8 lo . 511 fa r mod 22 28. 212 fa r fa r 5 6 . 4

T o ta ls 78 1 0 0 .0

As p r e v io u s ly s t a t e d , th e t o t a l number o f

78 p a t ie n t s in v o lv e d 81 empyemata, made up a s f o l lo w s

No. o f C ases

U n i la t e r a l pneumothoraxand empyema. 50B i l a t e r a l pneum othorax,u n i la t e r a l empyema 25B i l a t e r a l pneumothoraxand empyema 5

T o ta l 78

25

C la s s i f y in g th e s e th r e e Groups s e p a r a te ly

a c c o r d in g to th e c l a s s o f d i s e a s e on a d m issio n

r e s u l t s in th e f in d in g s sho?/n in T ah le 17.

TABLE 17

C l a s s i f i c a t i o n o f D is e a s e a t In d u c tio n o f Pneum othorax S a lk in and Cadden*s C l a s s i f i c a t i o n _ ___

'Modera t e l yAdvancedD is e a s e

ParAdvancedD is e a s e

No. o f C ases

% No. o f C ases

% T o ta l %

U n ila te r a l pneumothorax and empyema

16 20. 5 34 4 3 .6 50 6 4 .1

B i l a t e r a lpneumothoraxu n i la t e r a lempyema

8 1 0 .3 17 2 1 .8 25 32. 1

B i la t e r a l pneumothorax and empyema

0 0 3 3 .8 3 3 .8

T o ta ls 24 3 0 .8 54 6 9 .2 78 100 .0

Of th e 50 u n i l a t e r a l pneumothorax c a s e s , 34

(68%) were in th e fa r advanced c l a s s o f d is e a s e a t

in d u c tio n . Of th e 25 b i l a t e r a l pneumothorax c a s e s

w hich d ev e lo p ed u n i l a t e r a l empyema., 17 (68%) were in th e

26

f a r advanced c a te g o r y • A l l th r e e c a s e s w hich

d ev e lo p ed " b ila te r a l empyema came in t o th e f a r advanced

c a te g o r y o f d i s e a s e a t in d u c t io n o f pneum othorax.

T a b les 16 and 17 show th a t o n ly 24(30.7% )

o f c a s e s were in th e "moderate" c l a s s o f d i s e a s e on

a d m issio n . On th e o th e r hand, 54 (69.3% ) w ere in

th e " fa r advanced" c a te g o r y on a d m iss io n .

Only two c a s e s (2.5% ) had a c o n t r a - la t e r a l

lu n g th a t co u ld he c l a s s i f i e d as c l e a r , and in th e s e

two c a s e s th e d is e a s e in th e h o m o la te r a l lu n g was in

an advanced s t a t e .

As a lr e a d y s t a t e d , a l l pneum othoraces were

induced in from two to fo u r weeks from th e tim e o f

a d m issio n and i t i s r e a so n a b le to assum e th a t th e

c l a s s i f i c a t i o n o f d is e a s e a t th e tim e o f in d u c t io n

o f pneumothorax was s im i la r to th a t a t th e tim e o f

a d m issio n .

In v iew o f th e f a c t th a t th e above (S a lk in

and Cadden) c l a s s i f i c a t i o n g iv e s no in d ic a t io n o f

th e p a th o lo g y o f th e c a s e s , i t was d ec id e d to c l a s s i f y

th e c a s e s c l i n i c a l l y and r a d i o l l o g i c a l l y a c c o r d in g to

th e s u g g e s t io n o f R a f fe r ty (1 9 4 4 ) . T h is c l a s s i f i c a t i o n

i s shown in T ab le 18 on th e n e x t page.

27

TABLE 18 75 C ases

( C l a s s i f i e d a c c o r d in g to R a f fe r ty )

Group Type o f D is e a s e No. o f P a t ie n t s

%

1 Pneumonic or a c u te e x u d a t iv e 28 3 5 .9

2 L arge a p ic a l c a v i t y 19 2 4 .4

3 E x te n s iv e u n i l a t e r a l c a v i t a t io n 16 2 o .5

4 E n d ob ron ch ia l d is e a s e o f a m ajor bronchus 12 6 . 4

T o ta l 75 8 7 .2

Three c a s e s (12*8$) d id n o t come in to any o f th e above

c a t e g o r ie s . Two o f th e s e th r e e c a s e s had lo w er lo h e

c a v i t a t io n , and one d o r s a l lo h e c a v i t a t io n .

Prom T ah le 18 i t can he se e n th a t 63 ( e q u iv a le n t

to s l i g h t l y more than 80$ o f th e 78 c a s e s ) had e i t h e r

a c u te e x u d a t iv e d is e a s e o r advanced c a v i t a t io n .

4 . E r y th r o c y te S ed im en ta tio n R ate .

The e r y th r o c y te s e d im e n ta tio n r a t e , a s u n d ersto o d

in t h i s T h e s is , i s th e tw o -h o u r ly re a d in g in m i l l i

m etres (W esterg ren ). I t h as h een th e p r a c t ic e in

th e C h esh ire J o in t Sanatorium to e s t im a te th e

e r y th r o c y te s e d im e n ta tio n r a te ( e . s . r . ) a t one hour

and two hour i n t e r v a l s , th e secon d hour re a d in g h e in g

28

th e one u sed f o r p r a c t ic a l p u rp o ses .

E .S .R . a t Time o f In d u c tio n o f Pneum othorax.

E x p er ien ce o v er a number o f y e a r s h as

su g g e s te d th a t e f f u s io n in a r t i f i c i a l pneum othorax

h a s occu rred more f r e q u e n t ly in p a t ie n t s in whom

th e e . s . r . was 40 m. m. or more (2hours W estergren)

a t th e tim e o f in d u c t io n o f th e pneum othorax.

T ab le 19 shows th e E .S .R s . a t th e tim e o f

in d u c t io n o f 81 pneum othoraces w hich d ev e lo p ed empyemata.

TABLE 19

81 Pneum othoraces: E .S . R .(2 hour W estergren) a t tim e o f In d u c t io n o f Pneumothorax

S. S. R« m. m.

Number o f A. Ps. % o f A. P. s .

10 - 20 2 2. 521 - 30 3 3 .731 - 40 7 8 .641 - 50 18 2 2 .251 - 60 13 1 6 .161 - 70 7 8 .671 - 80 15 18. 581 - 90 8 9. 991 -1 0 0 6 7 .4OverlOO 2 2 .5

T o ta l 81 1 0 0 .0

I t can he se en from th e above T ab le

th a t 69 (85.2% ) o f th e pneum othoraces were induced

when th e se d im e n ta tio n r a te was more ra p id than

40 m. m. in 2 hours (W. ) .

29

■Further i n v e s t ig a t io n o f th e s e 69 c a s e s

was made, f i r s t l y in t o th e tim e in t e r v a l in weeks

w hich e la p se d heween th e in d u c t io n o f pneum othorax

and th e o n se t o f e f f u s io n , and s e c o n d ly , to a s c e r t a in

th e in t e r v a l b etw een th e appearance o f e f f u s io n and

i t s c o n v e r s io n t o empyema. T h is i s shown in T ab le 20

TABLE 20

69 Pneum othoraces ind u ced when E. S. R. was o v er 40 m.m.(W . )

A verage in t e r v a l in Weeks from In d u c tio n t i l l E f fu s io n and from E f fu s io n t i l l Empyema

E8.R.Oroup

ho. o f A. Ps.

A verage tim e from in d u c t io n o f A. P. t i l l

e f f u s io n Weeks

A verage in t e r v a l t i l l e f f u s io n co n v er ted to

empyema Weeks

41 - 50 18 17. 5 8 .651 - 60 15 1 -. 2 6 .061 - 70 7 1 3 .7 5 .471 - 80 15 13. 2 4 . 181 - 90 8 1 1 .0 P u ru len t91 -1 0 0 6 4 . 1 from f i r s tOver100 2 2. 5 a s p ir a t io n .

T o ta l 69

I t can be se e n from T ab le 20 th a t th e

h ig h e r th e se d im e n ta tio n r a te a t in d u c t io n o f

pneumothorax th e s h o r te r th e i n t e r v a l s bew teen o n se t

o f e f f u s io n and con seq u en t empyema.

A lthough o n ly s ix t e e n empyemata are shown

in t a b le 20 as h a v in g been p u ru len t from th e f i r s t

a s p ir a t io n th e r e were a l to g e th e r tw en ty -tw o (27.2% )

o f th e e ig h ty one empyemata p u ru len t from th e s t a r t .

30

D u ra tio n o f D is e a s e a t I n d u c t io n o f Pneum othorax.

H ayes(1927) h a s su g g e s te d th a t th e r e i s a

h ig h e r p r o p o r tio n o f empyemata among th o s e p a t ie n t s

in whom th e d is e a s e h a s heen o f s h o r t d u r a t io n p r io r

to in d u c t io n o f pneum othorax.

D u ra tio n o f symptoms p r io r to a d m iss io n f o r

th e 78 p a t ie n t s in t h i s s e r i e s i s shown in T ah le 21.

TAB-uE 21 78 C ases

D u ra tio n o f Symptoms p r io r to A d m ission

D u ra tio n o f Symptoms Months

Ho. o f P a t ie n t s

%

1 - 6 37 4 7 .47— 12 24 3 0 .8

13 -1 8 9 1 1 .519 - 2 4 4 5 .125 -3 6 2 2 .63 7 - 48 2 2 .6

T o ta l 78 1 0 0 .0

From T ah le 21 i t i s s e e n th a t 61 p a t ie n t s

(7 8 %) had symptoms o f a y e a r ’ s d u r a t io n o r l e s s . A l l

pneum othoraces were in d u ced w ith in an a v era g e p e r io d

o f 2 .7 w eeks from th e tim e o f a d m iss io n , w hich does

n o t m a t e r ia l ly a l t e r th e p o s i t io n a s fa r a s th e

a c u te n e s s o r o th e r w ise o f d i s e a s e a t th e t im e s o f

a d m iss io n and o f in d u c t io n o f th e pneum othorax i s

con cern ed .

31

5 . Type o f C o lla p se a f t e r a d h e s io n s e c t i o n .

In t h i s s e r i e s c a s e s w ere d iv id e d in t o

th r e e c l a s s e s a c c o r d in g t o th e ty p e o f c o l la p s e

1 . S a t i s f a c t o r y .

2 . In c o m p le te .

3 . I n e f f e c t i v e .

S a t is f a c t o r y c o l la p s e means a pneum othorax w ith

com plete r e la x a t io n o f th e a p e x , w ith no a d h e s io n s

t o th e l a t e r a l c h e s t w a l l and no a d h e s io n s to th e

upper m ediastinum above th e l e v e l o f the c l a v i c l e .

Incom plete c o l la p s e in c lu d e s a l l c a s e s w ith th e

lung apex a d h eren t to th e c u p o la , or w ith a d h e s io n s

t o th e m ediastinum a t th e a p ic o -m e d ia s t in a l a n g le .

I n e f f e c t iv e c o l la p s e In c lu d e s th o se c a s e s in whom

th e r e was m a ssiv e ad h erence o f th e ap ex t o th e dome

o f th e c h e s t , and a l l c a s e s in whom th e r e were

in o p er a b le a d h e s io n s t o th e l a t e r a l c h e s t w a l l ,

i r r e s p e c t iv e o f the a p ic a l r e la x a t io n . B efore

o p e r a t io n none o f th e c a s e s had a c o l la p s e th a t co u ld

be co n s id er e d a s s a t i s f a c t o r y .

The type o f c o l la p s e in ea ch o f th e 81

pneum othoraces i s shown in T able 22 w ith th e M in is tr y

o f H ea lth c l a s s i f i c a t i o n on a d m is s io n .

32

TABLE] 2 2

81 P neum othoraces• Type o f C o lla p se a f t e r A d h esion S e c t io n ,

Type o f C o lla p se

C l a s s i f i c a t i o n M in is tr y o f H ea lth

T o ta ls fo

1A2 RB2 RB3 No. $No. % No. % No. %

S a t i s fa c to r y 0 22 2 7 .2 4 4 .9 26 3 2 .1

Incomp le t e 1 1 .2 24 2 9 .6 5 6 .2 30 3 7 .0

In e f f e c t i v e 0 17 2 1 .0 8 9 .9 25 3 0 .9

T o ta l 1 1 .2 63 7 7 .8 17 2 1 .0 81 1 0 0 .0

Table 22 shows th a t f i f t y - f i v e (6 7 .9 $ ) o f

th e t o t a l number o f 81 pneum othoraces f e l l in to

e i t h e r th e in com p lete or i n e f f e c t i v e c la s s o f

c o l la p s e a f t e r a d h e s io n s e c t i o n . Not a l l th e

e ig h ty -o n e pneumo th o r a c e s , how ever, were o p era ted

upon. Five c a s e s , a l l o f w h ich came in t o th e

" in e f f e c t iv e " c la s s o f c o l la p s e were abandoned a f t e r

th o ra co sco p y (no a d h esio n s b ein g d iv id e d ) . Two

o th e r c a s e s a l s o c la s s e d a s having " in e f f e c t iv e "

c o l la p s e had t h e ir pneumo th o r a c e s abandoned b e fo r e

th o ra co sco p y b ecause empyema was a lr e a d y p r e s e n t .

33

6 . A t e l e c t a s i s .

Complete a t e l e c t a s i s o f t h e lung a f t e r

a d h e s i o n s e c t i o n d e v e l o p e d i n t w e l v e ( 1 6 .2 $ ) o f

t h e s e v e n t y - f o u r p n e u m o th o ra c e s s u b m i t t e d t o a d h e s i o n

s e c t i o n .

The r e l a t i o n s h i p o f a t e l e c t a s i s t o t h e

d e v e lo p m e n t o f empyema i n p n e um othorax w i l l be d e a l t

w i t h i n S e c t i o n 4 o f t h i s T h e s i s , i n D i s c u s s i o n on

E t i o l o g y o f Em pyem a i n t h e e i g h t y - o n e c a s e s u n d e r

r e v i e w .

T a b le 23 g i v e s d a t a on t h e s e tw e lv e c a s e s .

T h i s T a b le shows one o u t s t a n d i n g f e a t u r e , and t h a t i s

t h e d i s s i m i l a r i t y o f a l l t h e c a s e s e x c e p t , p e r h a p s ,

Nos. 4 and 10 . These two c a s e s had t u b e r c u l o u s

p l e u r a , and had s a t i s f a c t o r y c o l l a p s e w i t h f a i l u r e o f

t h e c a v i t y t o c l o s e . Bo th c a s e s d e v e l o p e d b r o n c h o

p l e u r a l f i s t u l a e .

None o f t h e tw e lv e c a s e s was s u b m i t t e d t o

b r onchos c o p y •

34 r.' ct J

~ l— -O r i cfi ft crf «H IO !h 3 Hfl ©13O 0 TO > 0!h H *rl 0 P-i

TJ o

TO0ft

Ois

f t -

Ois

030ft

TO TO0 0 0 0ft ft ft f t ft

to0ft

ois

oi s

G 10 433•H O-P 0 •Crf TO TOPi 0 ft 44P f t 43) TO fe;

O 0 < | Crf

fr-tO

O 0t>n

+3 Pift (S 0 ft00 O 00 0 TO 03 Pi f tP p

H OCM tO

OCM

Of t LOf tCO ! >f t

COto

•sH■4 1

TO 0 TO aJ o

a

to03

aCQ<rfIft

00• HTOCrf | •)0 0 I—I0

-p<rf

0 -P 0 I—Ift1o

IPi 0

-P H

e0is

0 Ig I JJ H . . n

i—i O S3 (D 0 -P 1 I P i 0f l d j L O H p O - H S ^H i> HH o P-I <! 0 -p 0 fe:

CO 03rl|Nft rH

H03f t 03

DOftCrfTO 03

IPi0

43>GH

Si—I ocrf Pi > f t

l+33crfo

IH H • •

f t i—I 0 4-3 DO£h f t -p O 440 4-3 -ft 0 f t

mf t

f t p Pi -P 0 Pi 0 f t TO 0 4-3 t> O -p 3c rf I— I f t c rf

O O crf OML

0ft TO fto p , p

crf Pi 0 0 H 0 4J p , f t 431 ft f t O P crf

C-t O rrt O

0 IP « G _* Hft TO O ft 0 prf 0 4 3 f t 0 > 0 H ^ fl 043 0 ftft ft 0 4 d O

f t 0 Pi Pi 0I

ft • O0 43) f t 43> O 0 Crf <3 0 p o

43)3

O•r~tmft o

o p

«:

r *ft Crf 0 O O

crf O 0 Pi crf •P 5 p f t cti 0 O f t40 ft P oCO P -i 4 0 o

f t0 Pi I Pi 0TO O 43) 0 43 ft d Pi G 0 crfft 0 P O

CO 'sH LO

TOftCrfP

t o

03 Oto

o ois

TO0ft

OisTO TO TO0 0 0 Oft ft ft ft

o oi s

0* I 433to S3 0 0 o ft f t O ft

qft

oft

qft

oft

Pi*■> 0 0

TO P , P0 a o ft dft

Pi•■•0 0

TO f t P0 a o ft p ft

Pi* 0 0

to a p 0 a o ft 3 ft o

ftoft

0TO •Crf Co ft

f t f t TO b f t DO f t TOf t f t 0 f t f t 0

f tf t 0

4-3 - p f t f t 43) -P f t f t 43) f t bf t f t f t P f t f t f t O f t f t f t O f t-P crf Crf Pi 43) crf Crf Pi -P 43) crf Pi 43(—1 = 0 0 0 f t S 0 0 f t f t © 0 f tcrf f t f t P Crf f t f t - P Crf Crf f t f t crf0 f t f t f t 0 ft f t f t 0 0 f t f t 0ft , P P 43> K P P -P P ir".1 P -P l ft

ft 03 to LO CO fr- OO 03c1—I ftI—1

to.

CO

of t

Inco

m

ple

te

r r

Sa

tisf

.

Inco

m

ple

te

Sa

tisf

.

Inc

om-

ple

te

r

Sa

tisf

.

= =

Inc

om-

ple

te

• TO TO TO DO0 O O 0 0 0 ft O 0 0 ft 0is is l ft ft f t is is is ft f t

oft

ft

36

7 . E x t e n t o f A d h e s i o n s .

A d h e s io n s e c t i o n b y c l o s e d p n e u m o l y s i s was

p e r fo r m e d i n s e v e n t y - f o u r ( 9 1 .4 $ ) o f t h e e i g h t y - o n e

p n e u m o t h o r a c e s . One c a s e , a f t e r two u n s u c c e s s f u l

s e s s i o n s o f c l o s e d p n e u m o l y s i s , was s u b j e c t e d t o open

p n e u m o l y s i s . His c o l l a p s e was s t i l l i n e f f e c t i v e a f t e r

open o p e r a t i o n . T a b le 24 shows t h e number o f pneumo

t h o r a c e s o p e r a t e d u p o n .

TABLE 24

74 Cases o f C losed P n eu m o ly s i s

U n i l a t e r a 1 pneum othorax

B i l a t e r a lpneum othorax

T o t a 1 €

Ho. o f Case s

<stto Ho. o f

Case so f/V

A d h es io ns e c t i o n 45 5 5 .6 29 3 5 . 8 74 9 1 .4

T h o r a c o s c o p y o n l y (no a d h e s i o n s d i v i d e d ) 4 5 . 0 1 1 .2 5 6.2Abandoned b e f o r e t h o r a c o s c o p y 1 1 .2 1 1 .2 2 2 . 4

T o t a l 50 6 1 .8 31 3 8 . 2 81 100 .0

The e x t e n t o f t h e a d h e s i o n s e x i s t i n g a f t e r

pneum othorax has b e en in d u c e d i s d i f f i c u l t t o a s s e s s ,

b u t may be c o n s i d e r e d a s d i r e c t l y r e l a t e d t o t h e t im e

s p e n t on a c t u a l c a u t e r i z a t i o n o f a d h e s i o n s . U n f o r t

u n a t e l y , t h e r e c o r d s o f t im e s p e n t on a c t u a l

37

a d h e s io n s e c t io n were reco rd ed in o n ly f o r t y - f i v e

(6 0 .8 $ ) o f th e s e v e n ty - fo u r c a s e s o p era ted upon .

Of th e se f o r t y - f i v e c a s e s , t w e n ty - s ix (5 7 .8 $ )

r e fe r r e d to c a s e s o f u n i l a t e r a l pneum othorax, and

s e v e n te e n (3 7 .8 $ ) to c a s e s o f b i l a t e r a l pneumothorax

w ith u n i l a t e r a l empyema, and two (4 .4 $ ) t o one ca se

o f b i l a t e r a l pneum othorax and empyema.

T a b les 2 5 , 26 and 27 show th e t im e s , in

m in u te s , sp e n t on a d h e s io n s e c t io n and th e a v era g e

in t e r v a l in weeks from a d h e s io n s e c t io n t i l l th e

o n se t o f empyema.

TABLE 2 5 . 26 C a ses .

Ad h e s io n S e c t io n : U n i la t e r a l Pneumo t h o r a c e s .

Time in m in u te s . S in g le S e s s io n s .

No. o f Case s .

Ave rag e in t e r v a 1 t i l l o n se t o f empyema.

Weeks

1 . Up to 30 3 202 3 1 - 4 5 8 153 4 6 - 6 0 7 74 6 1 - 7 5 3 4 . 35 7 6 - 9 0 2 2 . 56 Over 90 0 0

Double S e s s io n s .1 . 45 and 25 th en

open p n eu m olysis 1 Haemothorax w ith in24 h ou rs: pus in 6 w e e k s•

2 . 2 0 and 15 1 20

3 . 20 and 3 0 1 11

T o t a l *26

The d ouble s e s s io n s were afc in t e r v a l s o f

6 .5 w e e k s .

TABLE 2 6 . 17 C ases

B i l a t e r a l Pneum othoraces - U n i la t e r a l Empyema.

S in g le S e s s io n s M inute s

No. o f Ca se s o f A .P .

A verage in t e r v a l t i l l empyema •

Weeks

Up to 30 8 1131 - 45 3 946 - 60 3 661 - 75 0 076 - 90 0 0E x a c t ly 120 1 1

Double S e s s io n sM inutes

30 and 40 1 R e-a d m itted in26 weeks w ithempyema

45 and 5 1 15

T o ta l 17

TABLE 27

B i l a t e r a l Pneumothorax and Empyema

T h is ca se had a s in g le s e s s io n perform ed on e a ch s i d e .

Length o f S e s s io n . M inute s

I n t e r v a l t i l l empyema.

WeeksLe f t s id e 45 2

R igh t s id e induced 3 monthsa f t e r l e f t 10 5

39

The f ig u r e s in th e above T a b les would s u g g e s t th a t

th e lo n g e r th e tim e sp e n t on c a u t e r iz a t io n o f

a d h e s io n s ( in f e r r in g th a t th e a d h e s io n s were e x t e n s i v e ) ,

th e s h o r te r th e in t e r v a l u n t i l empyema su p er v en ed .

®• F lu id b e fo r e A dhesion S e c t io n .

Of th e 74 c a s e s o p era ted o n , o n ly th r e e (4 $ )

had s u f f i c i e n t f l u i d t o r e q u ir e a s p ir a t io n b e fo r e

o p e r a t io n . Two o th e r c a s e s had f l u i d t o th e 4 th

c o s t a l c a r t i l a g e , but t h i s a b so rb e d , and a t th e

tim e o f o p e r a t io n o n ly a sm a ll d iap h ragm atic puddle

rem ain ed .

The in t e r v a l th a t e la p se d in th e se f i v e c a s e s ,

betw een o p e r a t io n on a d h e sio n s and o n se t o f empyema,

i s shown b e lo w .

CaseNo.

E x ten t o f E f fu s io n b e fo r e

A dhesion S e c t io n .

I n te r v a l from a d h e s io n s e c t io n t i l l o n s e t o f empyema.

W eeks•

E ffu s io n t o 4 th c o s t a l c a r t i l a g e : not a s p ir a te d : absorbed to asupra d iap h ragm atic puddle by o p e r a t io n

E ffu s io n t o 2nd c o s t a l c a r t i l a g e . A sp ir a ted 3 tim es b e fo r e o p e r a t io n .

E ffu s io n t o 1 s t c o s t a l c a r t i la g e : a s p ir a te d 3 t im es b e fo r eo p e r a t io n .

40

CaseNo.

E x te n t o f E ffu d io n b e fo re

A d h esion S e c t io n .

. I n t e r v a l from a d h e s io n s e c t io n t i l l o n s e t o f empyema.

Weeks

4 . E f fu s io n t o 2nd c o s t a l c a r t i l a g e : a s p ir a te d tw ic e b e fo re o p e r a t io n . 13

5 . E f fu s io n t o 4 th c o s t a l c a r t i l a g e : n ot a s p ir a te d but absorbed b e fo r e o p e r a t io n 36

Of th e rem ain in g s ix t y - n in e c a s e s su b m itted

t o a d h e s io n s e c t i o n , f o r t y (58$ ) had o n ly a

d ia p h ra g m a tic puddle o f f l u i d in th e p er io d from

in d u c t io n t i l l a d h e s io n s e c t i o n . In t h ir t y - s e v e n

c a s e s w hich d ev e lo p ed empyema w ith in a p e r io d o f

weeks from a d h esio n s e c t i o n , th e average in t e r v a l

from a d h e s io n s e c t io n t i l l o n se t o f empyema was

1 0 .1 w eek s . T w enty-n ine c a se s (42 %) had no

f lu id b e fo re o p e r a t io n , and in tw e n ty -e ig h t in w hich

empyema d ev e lo p ed w ith in a p er io d o f w eeks from a d

h e s io n s e c t i o n , th e avera g e in t e r v a l from a d h e s io n

s e c t io n t i l l o n se t o f empyema was 1 1 .0 w eek s.

A p p aren tly th e p resen ce o f a d ia p h ra g m a tic

puddle o f f l u i d in th e in t e r v a l b etw een in d u c t io n o f

pneumothorax and c a u te r iz in g o f a d h e s io n s does not

m a te r ia l ly sh o r te n the in t e r v a l t i l l empyema d ev e lo p s

in c a s e s w hich d ev e lo p empyema.

41

9 . P o s i t iv e P r e ssu r e s in Pneum othorax#

T w en ty-fou r (2 9 .6 $ ) o f th e 81 pneum othoraces

in w h ich empyema d ev e lo p ed had p o s i t i v e p r e s su r e s

used t o m a in ta in th e pneumothorax p r io r t o a d h e s io n

s e c t i o n .

T h ir te e n (5 4 .1 $ ) o f the c a s e s in whom p o s i t i v e

p r e s su r e s were u sed were in S a lk in and Cadden*s (1941)

c l a s s i f i c a t i o n o f fa r advanced d i s e a s e . The rem a in

ing e le v e n c a s e s (4 5 .9 $ ) were in th e m o d era te ly

advanced d is e a s e c l a s s , s u g g e s t in g th a t in th e c a s e s

in whom p o s i t i v e p r e s su r e s had t o be u se d , th e

e x te n s iv e n ature o f th e d is e a s e had r e s u l t e d in

p r o p o r t io n a te ly e x t e n s iv e a d h e s io n s .

In s ix t e e n o f th e tw e n ty -fo u r c a s e s where

p o s i t iv e p r e s su r e s were u se d , th e tim e sp e n t on

c a u t e r iz a t io n o f a d h e s io n s was r e c o r d e d . In th e

o th er e ig h t c a s e s t im es were not r e c o r d e d . The

tim e in m inutes sp e n t c a u te r iz in g a d h e s io n s in th e

s ix t e e n c a s e s i s shown in Table 2 8 .

The tim e sp e n t on c a u t e r iz a t io n o f a d h e s

io n s in th e se c a s e s would su g g e s t th a t th e a d h es

io n s must have been f a i r l y e x t e n s iv e , and th a t

p o s i t iv e p r e s su r e s had to be used t o m a in ta in the

c o l la p s e .

42

TABLE 28 16 C a ses .

P o s i t iv e P ressu re Pneum othoraces

Time sp e n t on C a u te r iz a t io n o f a d h e s io n s in 16 p o s i t i v e p r e ssu r e p n eu m oth oraces.

No. o f C a se s .

Minute s :S in g le S e s s io n s .

Up t o 30 m in u tes 33 1 - 4 5 646 - 60 361 - 75 1

D ouble S e s s io n s20 and 15 m in u tes 130 and 40 ” 140 and 25 ” 1 1

T o ta l . 16

1 0 . C a v ity c lo su r e a f t e r a d h e s io n s e c t io n

The typ e o f c o l la p s e and s t a t e o f c a v i t y

c lo su r e w i l l be d e a l t w ith more f u l l y in a l a t e r

p a rt o f th e S e c t io n on E t io lo g y , but meantime th e

degree o f c a v i t y c lo su r e and type o f c o l la p s e ob

ta in e d in th e 74 c a s e s su b m itted to a d h e s io n s e c t io n

are a s shown in T able 29 b e lo w .

TAILS 2 9 . 74 Cases

C a v ity C losure a f t e r A d h esion S e c t io n

Type o f C o llap se • C av ity C lo se d . C av ity not c lo se d

T o ta l %Wo. % No. 7°

S a t is f a c t o r y 8 3 0 .8 18 6 9 .2 26 3 5 .1Incom plete 7 2 3 .3 23 7 6 .7 30 4 0 .5I n e f f e c t iv e 0 - 18 100. c 18 24*4T o ta l 15 20 .3 59 7 9 .7 74 10 0 .0

43

T able 29 shows th a t In f i f t y - n i n e (79,7%)

o f th e s e v e n ty - fo u r c a s e s su b m itted t o o p e r a t io n ,

in a lm o st f o u r - f i f t h s , i r r e s p e c t iv e o f th e typ e o f

c o l la p s e o b ta in e d , f a i lu r e to a c h ie v e c a v i t y c lo su r e

r e s u l t e d . Only o n e - f i f t h o f th e c a s e s had t h e i r

c a v i t i e s c lo s e d a f t e r a d h e s io n s e c t i o n , and in

ju s t under h a l f o f th e se c a s e s , th e c o l la p s e was

u n sa t i s f a c t o r y •

I f one adds to th e f i f t y - n i n e c a s e s shown in

Table 2 9 , in th e ” c a v it y not c lo s e d ” c l a s s , th e

sev en a d d it io n a l c a se s o f i n e f f e c t i v e c o l la p s e on

whom no o p e r a t io n was perform ed and c a v i t y c lo s u r e

was not o b ta in e d , th e number o f pneum othoraces

f a l l i n g in to t h i s c la s s r i s e s to s i x t y - s i x , r e p r e s e n t

ing 8 5 .2 $ o f th e t o t a l number o f e ig h ty -o n e pneumo

th o r a c e s .

1 1 . S ta te o f P leu ra a t T horacoscopy .

The s t a t e o f th e p leu ra a s see n a t th o ra co sco p y

was reco rd ed in se v e n ty (8 6 .4 $ ) o f th e p n eu m oth oraces.

In n in e c a s e s (1 1 .1 $ ) t h i s in fo r m a tio n was n ot r e c o r d e d ,

and in two c a s e s ( 2 .5 $ ) , the s t a t e o f th e p leu ra cou ld

not be a s c e r ta in e d owing to th e pneumothorax b e in g

abandoned b e fo re th o r a c o sc o p y .

44

The c o n d it io n o f th e p le u r a in th o se c a s e s

in w h ich i t was reco rd ed i s shown in T able 30 b e lo w .

The term " u n h ea lth y ” in d ic a t e s a p leu ra on w hich

a c t u a l t u b e r c le s were s e e n , or w h ich was e i t h e r

w h ite and sod d en , or angry red in a p p ea ra n ce .


S ta te o f P leu ra in 70 Pneum othoraces a s s e e n a tT horacoscopy ____ ________ __

I[ea lth y U n h ea lth y T o ta lNo. % No. % No J %

U n i la t e r a l pneumoth o ra x and empyema 21 23 44

B i l a t e r a l pneumoth o ra x and u n i l a t e r a l empyema 5 17 22

B i l a t e r a l empyema 3 1 4

T o ta l 29 4 1 .4 41 5 8 .6 70 1 0 0 .0

S ix o f th e 41 c a se s n o ted a s havin g u n h ea lth y p leu ra

had, in f a c t , numerous tu b e r c le s on th e v i s c e r a l and

p a r i e t a l p leu ra e .

Table 30 shows th a t n e a r ly 59% o f th e c a se s

in whom th e s t a t e o f th e p leu ra was known w ere seen

a t th o ra co sco p y to be u n h e a lth y .

45

1 2 . Broncho P le u r a l F i s t u la

Known b r o n c h o -p le u r a l f i s t u l a o ccu rred in

tw e n ty -e ig h t (3 4 .6 $ ) o f th e e ig h ty -o n e pneum othoraces

in w h ich empyema d e v e lo p e d .

F if te e n , f i s t u l a e (5 3 .6 $ ) occu rred in th e

f i f t y c a s e s o f u n i l a t e r a l pneum othorax. Tw elve

(4 2 .8 $ ) occu rred 6n th e h o m o la te r a l s id e in th e

tw e n ty - f iv e c a se s o f b i l a t e r a l pneum othorax, w h ile one

b r o n c h o -p le u r a l f i s t u l a (3 .6 ^ ) o ccu rred in th e s ix

pneum othoraces in v o lv e d in th e th r e e p a t ie n t s who

d ev e lo p ed b i l a t e r a l empyema.

Secondary in f e c t io n in c a se s o f B r o n ch o -p leu ra l f i s t u l a .

E ig h tee n (5 4 .3 ^ ) o f th e tw e n ty -e ig h t c a s e s

o f b r o n c h o -p le u r a l f i s t u l a produced im m ediate seco n d a ry

in f e c t io n o f th e pneumothorax space w h ile s im u lta n

e o u s ly ca u sin g tu b e r c u lo u s empyema. Thus o f th e

t o t a l o f t h i r t y - f i v e empyemata w hich became seco n d a r

i l y in f e c t e d , e ig h te e n (5 1 .4 $ ) owed t h e ir secon d ary

in f e c t io n to b r o n c h o -p le u r a l f i s t u l a e .

Type o f C o lla p se a nd S ta te o f Cavi t y C losure in c a se s o f ^ r o n ch o -p le u r a l V i s t u la .

Table 31 shows the type o f c o l la p s e a f t e r

a d h e s io n s e c t io n in tw e n ty -se v e n c a s e s o f b ron ch o

p le u r a l f i s t u l a . The rem ain in g case was n ot o p era ted

upon.

TABLE 3 1 21 G ases

B r o n c h o - p l e u r a l F i s t u l a e ; Tj/’pe o f C o l l a p s e ________ and S t a t e o f C a v i t y C l o s u r e __________

C a v i t y C lo s e d C a v i t y n o t C l o s e d

No. % No. crf/° T o t a l t'r4P

Type o f C o l l a p s e

S a t i s f a c t o r y 1 3 . 7 8 2 9 . 6 9 3 3 . 3

I n c o m p le t e 0 0 10 3 7 .1 10 3 7 .1

I n e f f e c t i v e 0 0 8 2 9 .6 8 2 9 . 8

T o t a l s 1 3 . 7 26 9 6 .3 27 1 0 0 .0

T a h le 31 shows t h a t t w e n t y - s i x o f t h e f i s t u l a e

e q u i v a l e n t to* 9 6 ^ , o c c u r r e d i n c a s e s o f c o l l a p s e i n

which c a v i t y c l o s u r e was n o t o b t a i n e d , P i n e c a s e s o f

f i s t u l a (32. I p o f t h e t o t a l number o f f i s t u l a e ) , o c c u r r e d

i n p n e u m o th o ra c e s c l a s s e d as s a t i s f a c t o r i l y c o l l a p s e d

a f t e r a d h e s i o n s e c t i o n , b u t i n o n ly one o f t h e s e

c o l l a p s e s was c a v i t y c l o s u r e o b t a i n e d . E i g h t e e n f i s t u l a e

o c c u r r e d i n c a s e s e i t h e r i n c o m p l e t e l y o r i n e f f e c t i v e l y

c o l l a p s e d , b u t i n none o f t h e s e c a s e s was c a v i t y c l o s u r e

o b t a i n e d .

One o t h e r c a s e o f f i s t u l a o c c u r r e d i n a pneumo

t h o r a x w i t h i n e f f e c t i v e c o l l a p s e . No a d h e s i o n s were d i v i d e d

47

when i t was found a t th o r a c o sc o p y th a t th e y were v ery

e x t e n s i v e . Adding t h i s ca se to th e e ig h t a lr e a d y

n o ted a s o ccu rr in g in c a s e s o f i n e f f e c t i v e c o l l a p s e ,

i t r a i s e s th e t o t a l number o f f i s t u l a e in t h i s c la s s

o f c o l la p s e to n in e , e q u iv a le n t t o 3 2 .1 $ o f th e t o t a l

number o f tw e n ty -e ig h t b r o n c h o -p le u r a l f i s t u l a e .

C l a s s i f i c a t i o n o f D ise a se a t In d u c tio n o f Pneumot horax in c a se s o f B ro n ch o -P leu ra l V i s t u la .

The tw e n ty -e ig h t c a se s w hich la t e r d ev e lo p ed

b r o n c h o -p le u r a l f i s t u l a were c l a s s i f i e d a cco rd in g

to th e typ e o f d is e a s e p r e se n t a t in d u c tio n o f pneumo

th orax (S a lk in and Cadden's c l a s s i f i c a t i o n ) . Table

32 shows th e c l a s s i f i c a t i o n .

TAB IS 3 2 . 28 C ases

Type o f D is e a s e . No. o f Cases %

M oderately advanced d is e a s e 9 32

Far advanced d is e a s e 19 68

T o ta l 28 100

Table 32 shows t h a t a l i t t l e over tw o -th ir d s o f th e

c a s e s w h ich d ev e lo p ed b r o n c h o - p le u r a lf is t u la were

In the " fa r advanced" c la s s o f d is e a s e a t in d u c tio n

o f pneum othorax.

48

S t a te o f P le u r a a t T horacoscopy

In th e tw e n ty -e ig h t c a s e s o f b r o n c h o -p le u r a l

f i s t u l a , th e p le u r a was found to he u n h ea lth y i n

tw e lv e (42 .9% ), h e a lth y in tw e lv e (42 .9% ), and was

n o t reco rd ed in fo u r c a s e s (14.2% ).

C auses o f B ro n c h o -P le u ra l F i s t u l a and I n t e r v a l from A d h esion S e c t io n

W ith in one week o f a d h es io n s e c t i o n : -

N in e c a s e s o f f i s t u l a o ccu rred w ith in one

week o f a d h esio n s e c t io n .

Three c a s e s were tra u m a tic a t o p e r a t io n ,

sp on tan eou s pneumothorax o r f i s t u l a o c c u r r in g a t

i n t e r v a ls o f 12 h o u r s , 48 h ou rs and 72 h ou rs r e s p e c t

i v e l y a f t e r o p e r a t io n .

Pour c a s e s s u f f e r e d ru p tu re o f t e n s io n

c a v i t i e s , two c a s e s o c c u r r in g th r e e days a f t e r

o p e r a t io n and two on th e sev en th day a f t e r o p e r a t io n .

In one o f th e s e c a s e s th e c o l la p s e was a p p a re n tly

s a t i s f a c t o r y , in two i t was in co m p le te and in one

i n e f f e c t i v e • In none was c a v i t y c lo s u r e o b ta in e d ;

on th e c o n tr a r y , a l l th e s e c a s e s had b a l lo o n in g

t e n s io n c a v i t i e s .

Two c a s e s s u f f e r e d f i s t u l a e through u n h e a lth y

us

t u b e r c u l o u s p l e u r a e on t h e s e v e n t h day f o l l o w i n g .

o p e r a t i o n . I n n e i t h e r c a s e was c a v i t y c l o s u r e

o b t a i n e d a l t h o u g h c o l l a p s e was s a t i s f a c t o r y i n one

c a s e b u t i n c o m p l e t e i n t h e o t h e r . One o f t h e s e

c a s e s was n o t e d a t t h o r a c o s c o p y t o hav e numerous

t u b e r c l e s on t h e v i s c e r a l p l e u r a , w h i l s t t h e o t h e r

h a d a d u l l w h i t e so d d e n p l e u r a w i t h a r e a s o f c a s e a t i o n

b e n e a t h . !

Of t h e r e m a i n i n g n i n e t e e n c a s e s o f b r o n c h o - p l e u r a l

f i s t u l a , e i g h t e e n o c c u r r e d a t i n t e r v a l s f o l l o w i n g

a d h e s i o n s e c t i o n as shown i n T a b le 33*

TABLE 3.3.

E i g h t e e n C a s e s o f B r o n c h o - p l e u r a l F i s t u l a : I n t e r v a l i n weeks f o l l o w i n g a d h e s i o n s e c t i o n t i l l o c c u r r e n c e o f F i s t u l a and a p p a r e n t C auses o f F i s t u l a e .

C ase No. I n t e r v a l prom o p e r a t i o n t i l l

f i s t u l a . Weeks

Cause o f F i s t u l a .

1 2 R u p tu r e d a p i c a l c a v i t y .

2 2 R u p t u r e d u p p e r l o b e c a v i t y .

3 3 R u p tu re t h r o u g h t u b e r c u l o u s p l e u r a !

h 3 R u p tu r e o f u p p e r l o b e cavi ty*

5 & R u p tu r e d a p i c a l c a v i t y1

6 51

R u p tu r e d u p p e r l o b e c a v i t y

7 7 R u p tu r e d a p i c a l c a v i t y .

50

TAB LB 55 (C on tin u ed )

Case No. I n t e r v a l from ' o p e r a t io n

t i l l f i s t u l a . Weeks

Cause o f F i s t u l a .

8 ? ! Rupturec a v i t y .

o f upper lob e

9 10 Rupturec a v i t y .

o f d o r s a l lo b e

10 10 Rupture o f upper lo b e c a v i t y .

11 14 Rupture o f a p ic a l c a v i t y .

12 16 Rupturestu d d ed

th rou gh p leu ra w ith t u b e r c l e s .

13 18 Rupture o f a p ic a l c a v i t y .

14 20 ))

20 )it it ti r»

15

16 24 ti it r» it

17 40 Rupture o f low er lob e c a v i t y .

18 68 Rupturec a v i t y .

o f d o r s a l lob e

One case on w hich no o p e r a t io n was p e r

formed and in whom pneumothorax was induced w h ile a

tu b e r c u lo u s pneumonia was p r e se n t s u f fe r e d broncho

p le u r a l f i s t u l a tw e lv e w eeks a f t e r in d u c tio n o f th e

pneumothorax and fo u r weeks from th o r a c o sc o p y . In

t h i s ca se the c o l la p s e had been induced and m a in ta in ed

by p o s i t i v e in tr a p le u r a l p r e s su r e s in th e p resen ce o f

tu b e r c u lo u s pneumonia and very e x t e n s iv e p le u r a l

a d h e s io n s •

51

Of th e tw e n ty -se v e n e a s e s su b m itted to

p n eu m o ly s is , th e c a u se s o f h p o n c h o -p le u r a l f i s t u l a

w ere a s f o l lo w s

1 . Three were due to trauma a t o p e r a t io n .

2. Twenty were due to ru p tu re o f c a v i t i e s .Seven o f th e s e c a s e s o ccu rred in a p p a r e n tly s a t i s f a c t o r i l y c o l la p s e d c a s e s , h u t in none was c a v i t y c lo s u r e o b ta in e d . The rem a in in g t h ir t e e n occu rred in c a s e s e i t h e r in c o m p le te ly o r i n e f f e c t i v e l y c o l la p s e d . One c a s e o f ru p tu red c a v i t y r e s u lt e d a f t e r 4 monthS trea tm en t by o le o th o r a x .

3. Four c a s e s o ccu rred from ru p tu re o f tu b e r c u lo u sf o c i through d is e a s e d p le u r a e . In one o f th e s e c a s e s c o l la p s e was com p lete and th e c a v i t y a p p a r e n tly c lo s e d , b u t sp on tan eou s pneumothorax o ccu rred 16 w eeks a f t e r o p e r a t io n . In t h i s c a se th e p le u r a was se e n a t th o ra co sco p y to be stu d d ed w ith t u b e r c le s . In th e o th e r th r e e c a s e s c a v i t y c lo s u r e was n o t o b ta in e dand th e c o l la p s e s were e i t h e r in co m p le te o r i n e f f e c t i v e .

In th r e e c a s e s w hich s u f f e r e d b r o n c h o -p le u r a l

f i s t u l a , d iap h ragm atic p a r a ly s i s by p h ren ic cru sh

was perform ed to a ttem p t to c lo s e a b a l lo o n in g t e n s io n

c a v i t y . In one o th e r c a se p h ren ic c r u sh , su p p le

m ented by pneum o-peritoneum was d one, b u t t h i s a l s o

f a i l e d to p rev en t th e c a v it y from e n la r g in g and

r u p tu r in g .

A t e l e c t a s i s in C ases o f B ro n ch o -p le u ra l F i s t u l a .

B r o n ch o -p leu ra l f i s t u l a was p reced ed by

com p lete a t e l e c t a s i s o f th e lu n g in f i v e c a s e s (18%)

52

a n d l o b a r a t e l e c t a s i s i n tw o c a s e s {7.1%) o f t h e t o t a l

number o f t w e n t y - e i g h t c a s e s i n w h i c h f i s t u l a o c c u r r e d .

13 • R e l a t i o n s h i p o f A d h e s i o n S e c t i o n t o O n s e t o f Tmoyema .

I t h a s b e e n shown i n t h e p r e c e d i n g p a g e s

t h a t t w e n t y - e i g h t o f t h e t o t a l o f e i g h t y - o n e empyemata

w ere due t o known b r o n c h o - p l e u r a l f i s t u l a e . T w e n ty -

s e v e n o f t h e s e c a s e s w e re s u b m i t t e d t o o p e r a t i o n .

A f t e r d e d u c t i n g t h e s e t w e n t y - s e v e n c a s e s f ro m t h e t o t a l

o f s e v e n t y - f o u r on whom a d h e s i o n s e c t i o n was p e r f o r m e d ,

f o r t y - s e v e n c a s e s r e m a i n f o r c o n s i d e r a t i o n .

S ix e m p y e m a ta , i n c l u d i n g one c a s e o f b i l a t e r a l

empyema, d i d n o t d e v e l o p t i l l b e t w e e n 1 a n d 3-| y e a r s

a f t e r a d h e s i o n s e c t i o n . I t i s u n l i k e l y t h a t o p e r a t i o n

w as a s s o c i a t e d w i t h t h e s u b s e q u e n t d e v e l o p m e n t o f empyema

i n t h e s e c a s e s , a l t h o u g h G o o r w i t c h (1943) q u o t e s Sm art

a s s t a t i n g t h a t empyema o c c u r r i n g w i t h i n one m on th t o

tw o y e a r s a f t e r a d h e s i o n s e c t i o n may p o s s i b l y be r e l a t e d

t o t h e o p e r a t i o n . The s i x c a s e s m e n t i o n e d a b o v e

w i l l be c o n s i d e r e d l a t e r . T h i s l e a v e s f o r t y - o n e

c a s e s o f empyema f o r c o n s i d e r a t i o n now i n r e l a t i o n t o

a d h e s i o n s e c t i o n .

53

T able 34 shows th e tim e in t e r v a l in weeks

b etw een th e o p e r a t io n o f a d h e s io n s e c t i o n and th e

su b seq u en t o n se t o f empyema in th e fo r ty -o n e c a s e s

m en tion ed a b o v e . For r e f e r e n c e , th e tw e n ty -se v e n

c a s e s o f b r o n c h o -p le u r a l f i s t u l a are in c lu d ed in

T able 3 4 .


I n t e r v a l b etw een A dhesion S e c t io n and O nset o f Empyema

I n t e r v a l in weeks from o p e r a t io n t i l l o n se t o f empyema.

No. o f C a ses: Cause s o fempyema t o be c o n s id e r e d .

No. o f C a ses: Empyema due t o b ron ch op le u r a l f i s t u l a .

T o ta l

1 . W ith in ' 1 wk. 4 9 13

2 . Between 1 and 2 wks • 4 2 6

3 . 2 and 3 0 2 2

4 . it 3 and 4 1 1 2

5 . it 4 and 5 1 0 1

6 . t! 5 and 6 2 0 2

7 . it 6 and 7 2 2 4

8 . ti 7 and 8 2 1 3

9 . it 8 and 9 1 0 1

10 t! 9 and 10 3 2 5

11 ff 10 and 11 3 0 3

12 tf 11 and 12 1 0 1T o ta l 24 19 43

54

TABLE 34 (C on tin u ed )

I n t e r v a l in w eeks from o p e r a t io n t i l l o n se t empyema.

o f

No. o f C ages: Causes o fempyema t o be c o n s id e r e d .

No • o f C ases: Empyema due to b ron ch op le u r a l f i s t u l a .

T o ta l

1 3 . Between 12 and I3wks 2 0 2

1 4 . ft 13 and 14 ti 1 1 2

1 5 . ?! 14 and 15 tr 1 0 1

1 6 . ir 15 and 16 rr 0 1 1

1 7 . ft 16 and 17 tf 0 0 0

1 8 . ff 17 and 18 ff 1 1 2

1 9 . ff 19 and 20 ft 1 2 3

2 0 . At 21 wks • 0 0 0

2 1 . At 24 1 1 2

2 2 . At 25 1 0 1

23 . At 26 1 0 1

2 4 . At 28 2 0 2

2 5 . At 32 2 0 2

2 6 . At 33 1 0 1

2 7 . At 36 1 0 1

2 8 . At 40 2 1 3

2 9 . At 68 0 1 1

T o ta l 41 27 68

55

I t was d e c i d e d a r b i t r a r i l y t o d i v i d e c a s e s

o f empyema n o t due t o known b r o n c h o - p l e u r a l f i s t u l a e

i n t o two g r o u p s : -

1 . Those i n w h ic h empyema d e v e l o p e d w i t h i n t w e l v e weeks o f a d h e s i o n s e c t i o n ; and

2 . Those i n w h ic h empyema d e v e l o p e d a f t e r a n i n t e r v a l o f more t h a n tw e l v e weeks f rom a d h e s i o n s e c t i o n .

T a b le 3 4 shows t h a t f o r t y - t h r e e (58.1%') o f

t h e s e v e n t y - f o u r c a s e s s u b m i t t e d t o a d h e s i o n s e c t i o n

d e v e l o p e d empyema w i t h i n tw e lv e weeks o f o p e r a t i o n .

Of t h e s e , n i n e t e e n ( 4 4 .2 $ ) were due t o b r o n c h o - p l e u r a l

f i s t u l a . The r e m a i n in g t w e n t y - f o u r c a s e s were due t o

o t h e r c a u s e s . These c a s e s w i l l be c o n s i d e r e d i n t h e

p a g e s i m m e d i a t e l y f o l l o w i n g .

S e v e n te e n c a s e s d e v e l o p e d empyema a f t e r an

i n t e r v a l o f b e tw een tw e lv e and f o r t y weeks f o l l o w i n g

a d h e s i o n s e c t i o n . These c a s e s w i l l be c o n s i d e r e d a f t e r

t h o s e w h ic h o c c u r r e d w i t h i n tw e lv e weeks o f a d h e s i o n s e c t i o n .

Three p a t i e n t s , i n v o l v i n g s i x p n eu m o th o ra c e s

who d e v e l o p e d b i l a t e r a l empyema w i l l be c o n s i d e r e d

s e p a r a t e l y b e c a u s e e a c h o f t h e s i x p n e u m o th o ra c e s came

i n t o d i f f e r e n t c a t e g o r i e s b o t h a s t o i n t e r v a l b e tw e e n

a d h e s i o n s e c t i o n and o n s e t o f empyema and ty p e o f c o l l a o s e

r e s u l t i n g a f t e r a d h e s i o n s e c t i o n . I n d i c a t i o n w i l l be

g i v e n where any o f t h e s i x empyemas come i n t o t h e f i r s t

o r second c a t e g o r i e s m en t ioned a b o v e .

56F i n a l l y , t h e r e v / i l l be c o n s i d e r e d t h e f i v e

p n e u m o th o ra c e s n o t s u b m i t t e d t o a d h e s i o n s e c t i o n .

Of two o t h e r p n e u m o th o ra c e s n o t s u b m i t t e d t o a d h e s i o n

s e c t i o n , one h a s b e e n c o n s i d e r e d a l r e a d y i n t h e c a s e s

i n w h i c h empyema was due t o b r o n c h o - p l e u r a l f i s t u l a ,

w h i l e t h e o t h e r v / i l l be i n c l u d e d i n t h e t h r e e c a s e s o f

b i l a t e r a l empyema.

T w e n t y - f o u r c a s e s o f Empyema w h ic h o c c u r r e d w i t h i n tw e l v e weeks o f A dhes ion S e c t i o n . '

Of t h e s e t w e n t y - f o u r c a s e s , two were due

d i r e c t l y t o a d h e s i o n s e c t i o n and f o u r t o i n d u c t i o n o f

p n eum othorax i n u n s u i t a b l e c a s e s w i t h a d h e s i o n s e c t i o n

p r e c i p i t a t i n g empyema. D e t a i l s o f t h e s e c a s e s a r e a s

f o l l o w s : -

1 . Two c a s e s d e v e l o p e d m ass ive h aem o th o rax one d a y and

f i v e days r e s p e c t i v e l y a f t e r o p e r a t i o n . Empyema f o l l o w e d

haem orrhage i n s i x weeks and e l e v e n weeks r e s p e c t i v e l y .

2 . Two c a s e s d e v e l o p e d empyema i n f o u r d ay s and s e v e n

days r e s p e c t i v e l y a f t e r o p e r a t i o n . A d h e s io n s e c t i o n

l a s t e d 65 m in u te s and 80 m in u te s r e s p e c t i v e l y , s u g g e s t

i n g t h e e x i s t e n c e o f e x t e n s i v e a d h e s i o n s . B o th c a s e s

had t u b e r c u l o u s pneumonia a t t h e t im e o f i n d u c t i o n o f

pneum othorax •

3 . Two c a s e s d e v e lo p e d empyema w i t h i n s even days o f

o p e r a t i o n . Bo th c a s e s had f a r advanced v e r y a c t i v e

d i s e a s e a t t h e t im e o f i n d u c t i o n o f pneum othorax and

57

b o th had u n h e a lth y tu b e r c u lo u s p le u r a e and a d h e s io n s .

The rem ain ing e ig h t e e n c a s e s in w h ich empyema

d e v e lo p e d w i t h in 12 weeks o f a d h e s io n s e c t i o n w i l l

now be c o n s id e r e d .

These c a s e s were c l a s s i f i e d a s f o l l o w s ,

a c c o r d in g t o :

1 • Type o f c o l la p s e and w hether c a v i t y c lo su r e r e s u l t e d a f t e r a d h e s io n s e c t i o n •

No. o f C a se s .

1 . S a t i s f a c t o r y c o l la p s e andc a v i t y c lo s u r e 1

2 . S a t i s f a c t o r y c o l la p s e andf a i l e d c a v i t y c lo s u r e 2

3 . Incom plete c o l la p s e andc a v i t y c lo s u r e 6

4 . Incom plete c o l la p s e andf a i l e d c a v i t y c lo s u r e 5

5 . I n e f f e c t i v e c o l la p s e andf a i l e d c a v i t y c lo s u r e _ 4

18

2 . Type o f D is e a se a t In d u c t io n o f Pneumothorax•

1 . A ccording t o th e M in is tr y o f H e a l th ’ s c l a s s i f i c a t io n f o r pulmonary t u b e r c u l o s i s , e . g . RA1, RB2,RB3.

2 . A ccording to S a lk in 8c Cadden's m o d i f i c a t io n o f th e c l a s s i f i c a t i o n adopted by the American T u b e r c u lo s is A s s o c ia t io n (1941) r e f e r r e d t o asS . & G. in th e T a b le s .Sub-groups 5 and 6 r e f e r to m o d era te ly advanced d i s e a s e ; sub-groups 7 , 8 , 9 , 10 , 11 and 12 r e f e r to fa r advanced d i s e a s e , th e s e v e r i t y o f th e d i s e a s e in c r e a s in g w ith th e grad in g numbers.

58

S a t i s f a c t o r y o o l la p s e w i t h ap p aren t c a v i t y c l o s u r e .

One case o n ly came in t o t h i s c a te g o r y -

a u n i l a t e r a l pneum othorax.

TABLhI 3 5 . 1 Case

Case'No.

C l a s s i f i c a t i o n o f D is e a se a t In d u c t io n o f pneum othorax.

E .S .R .a tin d u c t io n o f pneumothorax m.m.2 hrs • (W est.)

S ta te o fPleuraa tThoracosco p y

I n t e r v a lfromin d u c t io nt i l la d h esio ns e c t io n .Weeks

I n t e r v a lfroma d h e s io ns e c t i o nt i l lempyema•

Weeks

Min.o fH ea lth

S. & C,

1 RB2 10 54 U nhealthy (3 a s p i r a t i o n s be fo r e o p e r a t io n ) .

6 9

Remarks -

T h is case had a m assive e f f u s i o n to th e

second c o s t a l c a r t i l a g e th r e e weeks a f t e r in d u c t io n

o f th e pneumothorax, w h ich s u g g e s t s a p l e u r i t i s

e x i s t e d b e fo r e and a t th e time o f a d h e s io n s e c t i o n .

The lung d i s e a s e was a p p a r e n t ly fa r ad van ced , though

not v e r y a c u t e •

Cause o f empyema appears to have been o p e r a t io n in

the p resen ce o f f a r advanced lung d i s e a s e and

a c t i v e tu b e r c u lo u s p l e u r i t i s .

59

S a t i s f a c t o r y c o l la p s e and f a i l e d c a v i t y c l o s u r e •

Two c a s e s : Case 1 was a u n i l a t e r a l pneumo

t h o r a x . Case 2 was a b i l a t e r a l pneumothorax.

TA3IE 5 6 . 2 Case s

CaseNo.

C l a s s i f i c a t i o n a t in d u c t io no f A .P .

S .S .R .a tin d u c t

Sta te o fp leu ra

I n t e r v a lfrom

I n t e r v a lfrom

Min.o fH e a lth .

S. & C. io nm.m.2 hrs (w. )

a tThora- coscop y

in d u c t io nt i l lpneumoly s i s . W eeks•

pneumoly s i s t i l l empyema,

Weeks •

1 RB2 6 34 H ea lth y 6 8

2 RB2 8 29 Redi n flam edf l u i d

8 8

Remarks -

Case 1 was one o f moderate d i s e a s e and

a c t i v i t y a t in d u c t io n . D iaphragm atic p a r a l y s i s

by p h r e n ic cru sh was done in an a ttem p t t o c lo s e

the c a v i t y . The cause o f empyema i s n o t known.

I t may have been due t o :

( 1 ) A dhesion s e c t i o n .

(2) A slow b r o n c h o -p le u r a l f i s t u l a .( 3 ) F a i lu r e to a c h ie v e c a v i t y c lo su re*

Case 2 was one o f m o d era te ly f a r advanced

r e l a t i v e l y i n a c t i v e d i s e a s e a t in d u c t io n . P leura was

red and in flam ed and f l u i d was p r e s e n t a t o p e r a t io n ,

s u g g e s t in g t h a t a p l e u r i t i s e x i s t e d . The c a v i t y

in t h i s case was s i t u a t e d i n the l e f t low er lobe

and was b a s a l in s i t u a t i o n w i t h f l u i d l e v e l i n s i d e .

Empyema may have been due t o a d h e s io n s e c t i o n on a

red in fla m ed p leu ra or t o spread o f d i s e a s e from

the p a te n t c a v i t y .

Incom plete c o l la p s e and c a v i t y c l o s u r e .

TABL3 37 6 Cases

Cases N os. 1 , 2 , 3 and 4 were u n i l a t e r a l pneumo th o r a c e s • Cases Nos. 5 and 6 were b i l a t e r a l pneum othoraces.

CaseNo.

C l a s s i f i c a t i o n a t in d u c t io n .

3 .S .R .a t

S ta teo f

I n t e r v a l

I n t e r v a l

4

Min.o fH ea lth

S & C * • In d u c tio n o f A .P . m.m.2 hrs • (W.)

p leu raa tth o r a c o scopy

from in d u c t io n t i l l pneumoly s i s .We e k s .

frompneumol y s i st i l lempyema

Weeks

1 RB2 6 19 H ealth yf l u i d

7 10

2 RB2 5 20 H ea lth y 10 6

3 RB2 8 30 U nhea lthyw h itesodden

; 6 12

4 RB2 7 46 T u b erc le s 3 a s p i r a t io n s be fo re o p e r a t io n

7 7

5 RB2 6 31 W h ite , d u l l

8 10

6 RB2 11 38 Angry,red

6 2

61

Remarks -

Case 1 d e v e lo p e d pus by 10 weeks from a d h e s io n

s e c t i o n , in s p i t e o f moderate d i s e a s e and moderate

a c t i v i t y a t in d u c t io n . A dhesion s e c t i o n occu p ied

55 m in u te s . C o lla p se was in c o m p le te , suspended

a t the a p e x . Cause o f empyema may have b een t w o - f o ld :

(1 ) A dhesion s e c t i o n ; (2 ) m a in ta in in g u n re la x ed

c o l l a p s e o f lung w i th s t r e t c h in g o f the rem aining

adhe s i o n s •

Case 2: Moderate d i s e a s e and moderate a c

t i v i t y . M assive e f f u s i o n occu rred in 2 weeks

from o p e r a t io n . P o s i t i v e p r e s s u r e s were used to

m a in ta in an in com p lete c o l l a p s e . A p p aren tly t h i s

empyema was due to com bination o f a d h e s io n s e c t i o n and

m a in ta in in g by p o s i t i v e p r e s su r e s an in com p lete

c o l l a p s e .

Case 3: Moderate d i s e a s e and moderate a c t i v i t y .

P leura was in f e c t e d and p o s i t i v e p r e s su r e s were

used t o m a in ta in in com p lete c o l l a p s e . A dhesion

s e c t i o n took 70 m in u te s . Cause o f empyema was

e i t h e r a d h e s io n s e c t i o n or m a in ta in in g in com p lete

c o l la p s e in p resen ce o f tu b e r c u lo u s p leu ra and

a d h e s io n s , s t r e t c h e d by p o s i t i v e p r e s s u r e s .

Case 4: M oderately fa r advanced d i s e a s e ;

moderate a c t i v i t y . Pleura markedly t u b e r c u lo u s .

62

Complete a t e l e c t a s i s d e v e lo p e d 5 weeks from o p e r a t

i o n . Cause o f empyema a p p a r e n t ly was o p e r a t io n

on tu b e r c u lo u s p leu ra and p o s s i b l e spread from

a t e l e c t a t i c lu n g .

Case 5: Moderate d i s e a s e and moderate a c t i v i t y ;

p le u r a w h ite and d u l l . Complete a t e l e c t a s i s

d ev e lo p ed 1 week a f t e r o p e r a t io n . A dhesion s e c t i o n

l a s t e d 50 m in u te s . Cause o f empyema appears to

have b een a com bination o f :

1* O p eration on u n h ea lth y p leu ra and a d h e s io n s .

2 . Spread i n a t e l e c t a t i c lung t o p le u r a .

3 . M ain ta in in g u n re la x ed c o l la p s e suspended a t the a p e x .

Case 6 ; One o f f a r advanced m o d era te ly

a c t i v e d i s e a s e a t in d u c t io n o f pneumothorax. P leura

and a d h e s io n s red and a n g ry . Empyema in 2 weeks

f o l lo w in g a d h e s io n s e c t i o n s u g g e s t s t h a t the cause

was a d h e s io n s e c t i o n on an u n h ea lth y in flam ed p le u r a .

63

Incom plete c o l l a p s e and f a i l e d c a v i t y c l o s u r e .

TABLE 38 • 5 Cases

Four c a s e s (N os. 1 t o 4) were u n i l a t e r a l pneu m oth oraces . One case (No. 5) was one o f " b i la t e r a l pneumothorax.

CaseNo.

C l a s s i f i c a t i o n o f D ise a se a t in d u c t io n o f

A .P .

E .S .R .a tin d u c t io n o f

S ta te o fP leuraa tth o r a -

I n t e r v a lfromin d u c t

I n t e r v a lfrompneumol

Min.o fH e a l th .

S,& C. A .P . m.m.2 h r s .( w. )

coscop y io nt i l lpneumoly s i s . W eeks.

y s i st i l lo n se to f empyema Weeks

1 RB2 5 38 Red, d u sk y , so d d e n .

12 2

2 RB3 11 58 Soddenw h itef l u i d

12 4

3 RB2 8 55 H ea lth y 15 11

4 RA2 5 38 H ea lth y 7 8

5 • RB2 11 89 Tuberclesf l u i d

8 4

Remarks -

Case 1 . One o f moderate d i s e a s e and moderate

a c t i v i t y a t in d u c t io n . P leura r e d , dusky, so d d en .

P u ru len t empyema in 2 weeks from o p e r a t io n s u g g e s t s

a d h e s io n s e c t i o n was th e c a u s e .

Case 2 . One o f f a r advanced f a i r l y a c t i v e

d i s e a s e a t in d u c t io n . P o s i t i v e p r e s su r e s were used

t o m ain ta in c o l l a p s e . E f f u s io n t o the 4 th c o s t a l

64

c a r t i l a g e e x i s t e d p r io r to o p e r a t io n . T h is would

s u g g e s t a p l e u r i t i s e x i s t e d b e fo r e o p e r a t io n .

Empyema appears to have b een due to a com b in ation

o f f a c t o r s such as ;

1. M aintenance o f in c o m p le te c o l l a p s e by p o s i t i v e p r e s s u r e s .

2. A d h esion s e c t i o n on tu b e r c u lo u s p le u r a .• • • • • • • •

Case 5. One o f m o d era te ly advanced d i s e a s e

and m oderate a c t i v i t y a t in d u c t io n . A dhesion s e c t i o n

o c c u p ie d 60 m in u tes . Complete a t e l e c t a s i s d e v e lo p e d

e i g h t weeks a f t e r o p e r a t io n . Empyema appears t o

have b een due t o com b in ation o f :

1. The p r e se n c e o f e n d o -b r o n c h ia l d i s e a s e and developm ent o f a t e l e c t a s i s , which became com p le te .

2. E x te n s iv e a d h e s io n s e c t i o n .

3. M aintenance o f in co m p le te c o l l a p s e .

Case 4. One o f m o d era te ly advanced and

m o d era te ly a c t i v e d i s e a s e . Complete a t e l e c t a s i s

d e v e lo p e d sev e n weeks a f t e r o p e r a t io n . Cause o f

empyema seems to have b een due to th e same f a c t o r s

a s Case 3 above.

Case 5. One o f f a r advanced a c t i v e d i s e a s e

a t in d u c t io n . P leu ra studded w ith t u b e r c l e s .

Empyema was due a p p a r e n t ly to a d h e s io n s e c t i o n

i n th e p resen ce o f an a c u t e ly tu b e r c u lo u s p leu ra .

65

I n e f f e c t i v e c o l la p s e and f a i l e d c a v i t y c lo s u r e •

TA3L5J59. 4 Cases*

Four pneumothoraces f e l l in t o t h i s c a t e g o r y , hut c a se 4 w i l l he o m itted as i t was one h a l f o f a b i l a t e r a l empyema and w i l l he d e a l t w i th l a t e r .

Cases N os. 1 and 2 were u n i l a t e r a l p n eum othoraces .

Case No. 3 was one o f b i l a t e r a l pneumothorax.CaseNo.

C l a s s i f i c a t i o n o f D is e a se a t in d u c t io n o f

A .P .

‘E .S .R .a tIn d u c tion o f

S ta te o fPleuraa tt h o r a



Min.o fH e a l th .

S. & C. A .P . m.m.2 h r s .( w. )

coscop y io n o f A .P .t i l lpneumoly s i s • W eeks.

y s i st i l lo n s e t o f

-empyema

W eeks.

1 RB2 8 74 H ea lth y 8 5

2 R12 11 80 Nots t a t e d

15 10

3 RB2 6 76 Sodden,darkred

11 2

Remarks -

Case 1 . M oderately f a r advanced hut a c u t e l y

a c t i v e d i s e a s e a t in d u c t io n o f pneumothorax. Phrenic

c ru sh and pneumoperitoneum were performed t o supplem ent

1n e f fe c t i v e c o l l a p s e •

Causes o f empyema com bination o f f a c t o r s :

1 . C o llap se by pneumothorax o f a c u t e l y a c t i v e advanced d i s e a s e In lu n g •

662. F a i l u r e t o c o n t r o l d i s e a s e by p n eu m o th o ra x o r

d i a p h r a g m a t ic p a r a l y s i s and p n eu m o -p e r i to n eu m .

3- A d h e s io n s e c t i o n .

C ase 2: F a r a d v an ced a c t i v e d i s e a s e a t

i n d u c t i o n o f p n eu m o th o ra x . C o l l a p s e m a in t a in e d by

p o s i t i v e p r e s s u r e s f o r 15 weeks p r i o r t o a d h e s io n

s e c t i o n . A f t e r e f f u s i o n d e v e lo p e d h ig h n e g a t i v e

p r e s s u r e s w ere u s e d i n a t t e m p t s t o g e t t h e l u n g t o

r e - e x p a n d r a p i d l y . Two a p i c a l c a v i t i e s r e m a in e d

p a t e n t d e s p i t e pn eu m o th o rax and d ia p h r a g m a t ic

p a r a l y s i s by p h r e n i c e v u l s i o n .

C a u se s o f Empyema :

1 C o l l a p s e by p n eum otho rax o f a c u t e a c t i v e l y d i s e a s e d lu n g .

2 M a in t a i n i n g i r m e f f e o t i v e d e - s e l e c t i v e c o l l a p s e w i th s t r e t c h i n g o f a d h e s io n s by p o s i t i v e i n t r a p l e u r a l p r e s s u r e s end f a i l u r e t o g e t c a v i t y c l o s u r e .

3. P o s s i b l e s low b r o n c h o - p l e u r a l f i s t u l a f rom th e e f f e c t o f r e p e a t e d and p ro lo n g e d u s e o f h ig h n e g a t i v e i n t r a - p l e u r a l p r e s s u r e s a f t e r a s p i r a t i o n .

C ase 3 : M odera te b u t v e r y a c t i v e d i s e a s e ;

p l e u r a d a rk r e d and in f la m e d . P u r u l e n t e f f u s i o n i n

two weeks from o p e r a t i o n on a d h e s io n s s u g g e s t s t h a t

empyema i n t h i s c a s e was due to a d h e s io n s e c t i o n on

u n h e a l t h y p l e u r a and a d h e s io n s .

Summary o f C auses o r Empyema in tw en ty - Tour c a s e s

in which I t occu rred w i t h in 12 weeks o f A dhesion S e c t io n .

Only tw en ty - th r e e empyemata a r e , i n f a c t ,

in c lu d e d under th e above h ea d in g ; th e rem ain in g c a se

i s c o n s id e r e d w ith th e s i x pneumothoraces in v o lv e d m

th e th r e e p a t i e n t s who d e v e lo p e d b i l a t e r a l empyema.

The p r i n c i p a l c a u se s o f empyema in t h e s e

tw e n ty - th r e e c a s e s seem t o have been

1. A dhesion s e c t i o n a lo n e or v ery p o s s i b l y th e

e x i s t e n c e o f an u n h ea lth y p le u r a , r a th e r than th e o p e r a t io n

a lo n e , i r r e s p e c t i v e o f th e typ e o f c o l l a p s e ,was

r e s p o n s ib le i n tw e lv e , or j u s t o v er 50/b o f th e c a s e s .

I f a d h e s io n s e c t i o n were s o l e l y t o blame in t h e s e c a s e s

v ery e a r l y e f f u s i o n would be ex p e c te d .

2. In t e n c a s e s a com bination o f f a c t o r s seem t o

have been r e s p o n s ib le f o r th e empyemata. These f a c t o r s

were

1. “F a i lu r e t o a c h ie v e c a v i t y c lo s u r e

2 . The p rese n c e o f u n h ea lth y in fla m ed p leu ra and a d h es io n s e c t i o n on such p leu ra .

3. M a in ta in in g in co m p le te or i n e f f e c t i v e c o l l a p s e w ith u n c o n tr o l le d d i s e a s e and th e s t r e t c h i n g o f u n h ea lth y a d h es io n s by p o s i t i v e i n t r a - p l e u r a l p r e s s u r e s .

4. Complete a t e l e c t a s i s su p erven in g a f t e r a d h esio n s e c t i o n . Complete a t e l e c t a s i s d e v e lo p in g a l s o s u g g e s t s en d ob ron ch ia l d i s e a s e was p r e se n t .

5. In one ca se th e cau se i s n o t known.

6 8 .

14• S e v en teen o a se s d e v e lo p in g empyema betw een

tw e lv e and f o r t y weeks a f t e r a d h e s io n s e c t i o n •

I t i s not su g g e s te d t h a t s e v e n te e n c a s e s

w h ich d ev e lo p ed empyema a f t e r an i n t e r v a l vary in g

betw een tw e lv e and f o r t y weeks from th e date o f

a d h e s io n s e c t i o n owed the occu rren ce o f empyema

d i r e c t l y to the o p e r a t io n . They a re d e s c r ib e d

under t h a t heading a s a m atter o f con ven ien ce and to

p erm it o f com parison w i t h the p r e v io u s tw e n ty - fo u r

c a s e s w h ich occu rred a t i n t e r v a l s up t o tw e lv e weeks

f o l lo w in g o p e r a t io n .

These se v e n te e n c a s e s w i l l be c l a s s i f i e d in

s im i l a r f a s h io n , th a t i s , a cco rd in g to :

1* Type o f c o l la p s e and w hether c a v i t y c lo s u r e was o b ta in ed or not a f t e r a d h e s io n s e c t i o n .

2 . A ccording to the typ e o f d i s e a s e e x i s t i n g a t the in d u c t io n o f pneumothorax

c l a s s i f i e d ( 1 ) a cco rd in g t o th e c l a s s i f i c a t i o n o f the M in is tr y o f H e a lth .

(2 ) According t o th e c l a s s i f i c a t i o n o f the American T u b e r c u lo s is A s s o c ia t io n as m o d if ied by S a lk in and Cadden.

The type o f c o l la p s e and s t a t e o f c a v i t y

c lo s u r e in the s e v e n te e n ca se s now to be c o n s id e r e d

was a s f o l l o w s : -

69No. o f G ases .

1 . S a t i s f a c t o r y c o l l a p s e : c a v i t y c lo s e d 4

2 . S a t i s f a c t o r y c o l l a p s e : f a i l e dc a v i t y c lo s u r e 5

3 . Incom plete c o l l a p s e : c a v i t y c lo s e d 1

4 . Incom plete c o l l a p s e ; f a i l e d c a v i t yc lo s u r e 4

5 . I n e f f e c t i v e c o l l a p s e ; f a i l e d c a v i t yc lo s u r e 3

17

Sa t i s f a c t o r y c o l l a p s e and c a v i t y c l o s e d .

TABLE 4 0 . 4 c a s e s .

Cases 1 , 2 and 3 were u n i l a t e r a l pneumothorax. Case 4 b i l a t e r a l pneumothorax.

CaseNo.


A .P .

E .S .R .a tinduct io n of

S ta te ofPleuraa tth o r a -



Min.o fHea1th

S.& C. A .P . m.m.2 h r s . (w .)

coscop y io n t i l l pneumol y s i s Wee ks

y s i st i l lempyema

Weeks

1 RB2 8 60 Dusky red f lu id 2 a s p i r a t io n s

18 13

2 RB2 10 56 Red, i n flamed

6 18

3 RB2 11 57 Red, i n flamed

8 24

4 R32 8 85 H ea lth y 8 26

Remarks -

Case Is One o f m o d era te ly fa r advanced

f a i r l y a c t i v e d i s e a s e a t in d u c t io n . A s p ir a t io n

had t o be done tw ic e b e fo r e o p e r a t io n , s u g g e s t in g

a p l e u r i t i s e x i s t e d th e n . Complete a t e l e c t a s i s

d e v e lo p e d one week a f t e r o p e r a t io n .

Causes o f empyema: A dhesion s e c t i o n on d i s e a s e d

p le u r a and the e f f e c t s o f com plete a t e l e c t a s i s .

Case 2: One o f fa r advanced d i s e a s e and

m oderate a c t i v i t y a t in d u c t io n . Haemothorax

f o l lo w e d 3 days a f t e r o p e r a t io n .

Causes o f empyema: A dhesion s e c t i o n and haem othorax.

Case 3: F&r advanced a c t i v e d i s e a s e a t in d u c t

i o n . P leura u n h e a lth y . A dhesion s e c t i o n occu p ied

55 m in u te s .

Cause o f empyema: Not known - can o n ly be surm ised

t h a t a p r e - e x i s t i n g p l e u r i t i s was a g g ra v a ted by

o p e r a t io n .

Case 4: M oderately fa r advanced but very

a c t i v e d i s e a s e a t in d u c t io n o f pneumothorax.

Empyema in t h i s c a se .m u st have been due1to :

1 . C o llap se by pneumothorax o f a lung a f f e c t e d by a c u t e l y a c t i v e d is se m in a te d d i s e a s ew hich was u n s u i ta b le fo r trea tm en t by c o l l a p s e .

2 . Spread t o p leu ra d e s p i t e s a t i s f a c t o r y c o l la p s e and c a v i t y c lo s u r e .

71

S a t i s f a c t o r y c o l la p s e - f a i l e d c a v i t y c lo su r e

TABLE 4 1 . 5 Gases

Cases Nos. 1 to 3 were u n i l a t e r a l pneuraothoraees.

Cases Nos. 4 and 5 were b i l a t e r a l pn eu m oth oraces .

CaseNo.

C l a s s i f i c a t i o n o f D is e a s e a t in d u c t io n o f

A .P .

E .S .R .a tin d u c t io n o f A .P . m.m.2 hr s (W.)

S ta teo fPleuraa tthora - coscop y

I n t e r v a lfromin d u c t iont i l lpneumol y s i s(Weeks

I n t e r v a lfrompneumol y s i st i l lempyema

(Weeks)

Min.o fH e a lth

S & C

1 RB2 9 67 H ealth y 8 32

2 RB2 10 36 H 7 33

3 RB2 11 70 Not 6 20s t a t e d

4 RB2 6 14 H ealthy 8 32

5 RB2 11 93 tf 7 28

Remarks -

Case 1 was one o f f a r advanced a c t i v e d i s e a s e

a t in d u c t io n . Complete a t e l e c t a s i s d ev e lo p ed 30 weeks

a f t e r a d h es io n s e c t i o n . Empyema fo l lo w e d two weeks

l a t e r . Phrenic e v u l s io n had been done p r e v io u s ly

t o a ttem p t to c lo s e the c a v i t y .

Cause s o f empyema a p p a r e n t ly due to three- faetor-s

1 . C o l l a p s e of a c u t e l y d i s e a s e d l u n g .

2 . Occurrence of complete a t e l e c t a s i s .3 . f a i l u r e to a c h ie v e c a v i t y c lo s u r e .

72.

Case 2 : One o f f a r advanced b u t o n ly m o d era te ly

a c t i v e d i s e a s e a t ind u ction * P leu ra h ea lth y*

Cause o f empyema n o t known : may have "been spread

to p le u r a from u n c o n t r o l l e d lu n g d i s e a s e .

Case 3: One o f f a r advanced a c t i v e d i s e a s e a t

in d u c t io n o f A. P.

Cause o f emwema appears t o have "been spread from

u n c o n t r o l l e d lu n g d i s e a s e to p le u r a .

Case 4: M oderately advanced , m od erate ly

a c t i v e d i s e a s e a t in d u c t io n . A la r g e p e r ip h e r a l

c a v i t y remained p a te n t in an a t e l e c t a t i c upper lo h e .

Cause o f emwema: B ro n c h o -p le u r a l f i s t u l a was n o t

proved but from th e r a d i o l o g i c a l appearances a f t e r

empyema d ev e lo p ed t h i s would appear to have b een th e

c a u se . Spread o f d i s e a s e to th e p le u r a w ith con seq uent

r u p t u r e ( s l o w l y ) o f th e p e r ip h e r a l c a v i t y appears to

have occurred*

Case 5; Very a c t i v e w id e ly d is s e m in a te d d i s e a s e

w ith m u l t ip l e c a v i ta t io n *

C auses o f empyema :

1. C o l la p se o f a c u t e ly a c t i v e c a v i t a t e d lu n g , u n s u i t a b le f o r pneumothorax.

2* Spread from u n c o n tr o l le d lu n g d i s e a s e to p leu ra .

73Incomplete collapse - cavity closed.

TABLE k2 1 c a s e : U n i l a t e r a l Pneumot h o r a x .

C aseNo.

C l a s s i f i c a t i o n o f d i s e a s e a t i n d u c t i o n o f

A. P.

E. S.R.a ti n d u c t i o n o f A. P m. m 2 h r s (W)

S t a t eo fP l e u r aa tt h o r a cosco p y

I n t e r v a lfromi n d u c t i o nt i l lpneumol y s i s(Weeks)

I n t e r v a lfrompneumol y s i st i l lempyema

(W eeks)

Min.o fH e a l t h

S.& C.

1 RB2 5 9 H e a l th y 8

...................

15

Rem arks -

Case o f v e ry m o d e ra te ly ad v an ced d i s e a s e

and s l i g h t a c t i v i t y a t i n d u c t i o n o f p n eu m o th o ra x .

C o m p le te a t e l e c t a s i s d e v e lo p e d k weeks a f t e r a d h e s io n

s e c t i o n .

C au ses o f empyema - c o m b in a t io n o f two f a c t o r s : -

1 . M a in t a in in g in c o m p le te c o l l a p s e .

2. O c c u rre n c e o f c o m p le te a t e l e c t a s i s - .

74

Incom plete c o l la p s e - f a i l e d c a v i t y c lo s u r e •

TAB IE 45 » 4 c a s e s

Cases 1 and 2 were u n i l a t e r a l pneum othoraces.

Cases 3 and 4 were b i l a t e r a l pneum othoraces.

CaseNo.

C l a s s i f i c a t i o n o f d i s e a s e a t in d u c t io n o f

A .P .Min. S & C ofH e a lth

2 .S .R .a tin d u c t io n o f A .P . m.m.2 hrs (W.)

S ta teo fP leuraa tt h o r a coscop y

I n t e r v a l from in d u c t ion t i l l pneumol y s i s (Weeks)

I n t e r v a l from pneumol y s i s t i l l empyema

(Weeks)

1 RB2 6 76 Angry, in f la m e d , a i r a d h e s io n s a l s o

8 28

2 RB2 7 45 Soddenw h ite

6 14

3 RB2 8 28 Angryand s e n k i tiv ep leu ra and a d h e s io n s

7 36

4 RB3 12 78 Not known:f l u i dp r e s e n t

12 40

Remarks -

Case 1: Case o f m od erate ly advanced d i s e a s e

b u t a c u t e l y a c t i v e d i s e a s e a t in d u c t io n o f pneumo

th o r a x , P leura and a d h es io n s in flam ed and a n g ry .

P o s i t i v e p r e s su r e s used t o m a in ta in c o l l a p s e .

Lobar a t e l e c t a s i s d eve lop ed 4 weeks a f t e r a d h e s io n s e c t i o n .

75

Causes o f empyema: A p p aren tly a com b in ation o f

th e f o l lo w in g f a c t o r s

1. Pneumothorax induced in s t a t e o f a c u te a c t i v i t y o f d i s e a s e * , and f a i l e d c a v i t y c lo s u r e .

2 . P o s i t i v e p r e s s u r e s used to m a in ta in a c o l l a p s e w id e ly ad h eren t a t apex.

Case 2: One o f m o d era te ly f a r advanced and

m o d era te ly a c t i v e d i s e a s e a t in d u c t io n . P leu ra

u n h e a lth y .

Cause o f empyema n o t known ,b u t may have "been due

t o a com b in ation o f th e f o l l o w in g f a c t o r s

1. M a in ta in in g in co m p le te c o l l a p s e .

2 . A dhesion s e c t i o n on u n h ea lth y tu b e r c u lo u s p l e u r a l a d h e s io n s .

3. U n c o n tr o l le d lu n g d i s e a s e a l lo w in g spread t o p le u r a .

Case 3 : One o f m od erate ly f a r advanced,

r e l a t i v e l y i n a c t i v e d i s e a s e a t in d u c t io n . P leu ra

and a d h e s io n s angry and in flam ed .

Cause o f empyema n o t d e f i n i t e l y known but may have

b een due to

1. M a in ta in in g in co m p le te c o l l a p s e .

2. Spread o f u n c o n tr o l le d lu n g d i s e a s e t o p le u r a .

A dhesion s e c t i o n was done 36 weeks p r io r to empyema

d e v e lo p in g and can rea so n a b ly be e x o n era ted from blame.

76

Case 4: One o f fa r advanced d is s e m in a te d

a c u t e l y a c t i v e d i s e a s e a t in d u c t io n . Incom plete

c o l l a p s e m a in ta in ed fo r th ree months p r io r to

a d h e s io n s e c t i o n . F lu id p r e s e n t a t o p e r a t io n .

Causes o f empyema;

1 . C o lla p se o f lung in w hich th e r e was a c u t e l y a c t i v e w id espread d i s e a s e .

2 . M ain ta in in g in com p lete c o l l a p s e .

3 . U n c o n tr o l le d d i s e a s e a l lo w in g spread t o p le u r a .

I n e f f e c t i v e c o l la p s e and f a i l e d c a v i t y c lo s u r e

Three empyemata, in f a c t , f e l l i n t o th e

above c a t e g o r y , b u t one i s ex c lu d ed as i t occurred

in a p a t i e n t w ith b i l a t e r a l empyema. T h is case

w i l l be c o n s id e r e d w i th th e b i l a t e r a l empyemata.

TABLE 4 4 . 2 Cases

CaseNo.

C l a s s i f i c a t i o n o f d i s e a s e a t in d u c t io n o f

A .P .

E .S .R .a tin d u c t io n .

S ta te o f Pleura a t th o r a coscop y


I n t e r v a lfrompneumo

Min.ofH e a lth .

S & C. m.m.2 hrs(W. )

io nt i l lpneumoly s i s (w eek s)

l y s i st i l lempyema

(Weeks)

1 RB3 8 5 Angry red 24 40

2 RB2 10 72 l u s t r e - l e s s f i b r i n p r e se n t

6 13

Remarks -

Case 1: One o f m o d era te ly f a r advanced d i s e a s e

and m oderate a c t i v i t y a t in d u c t io n . P leu ra u n h e a lth y

a d h es io n s e c t i o n took 75 m in u tes . C a v ity remained

open.

Cause8 o f empyema n o t d e f i n t e l y known h u t may have

h een due t o a com bination o f f a c t o r s such a s t -

1. F a i lu r e t o b r in g about c a v i t y c lo s u r e .

2. M a in ta in in g b e fo r e and a f t e r a d h es io n s e c t i o n an i n e f f e c t i v e c o l l a p s e f o r 16 months i n a c a se o f m u lt ip le c a v i t a t i o n , u n s u i t a b le f o r c o l l a p s e by pneumothorax.

3. E x te n s iv e a d h e s io n s ; in flam ed a d h es io n s e x i s t e d b e fo r e and a f t e r a d h es io n s e c t i o n , but th e c o l l a p s e was m ain ta in ed .

Case 2; One o f f a r advanced a c t i v e d i s e a s e ; p leu ra u n h ea lth y .

Causes o f empyema - as in Case 1 above w ith th e

p o s s i b l e a g g r a v a t in g e f f e c t o f a d h esio n s e c t i o n

on an u n h ea lth y p leura as an a d d i t io n a l f a c t o r .

78

Summary o f Causes o f Empyema in 17 c a s e s in which

i t occu rred betw een 12 and 40 weeks from A dhesion

S e c t i o n .

Only s i x t e e n c a s e s a r e , i n f a c t , in c lu d e d

i n th e above c a te g o r y ; th e rem ain ing empyema w i l l

be c o n s id e r e d w ith th e b i l a t e r a l empyemata.

The p r in c ip a l c a u ses o f empyema in t h e s e

s i x t e e n c a s e s are as f o l l o w s . I t i s a d v is a b le t o

s t a t e th a t th e c a u s a l f a c t o r s are n ot ta b u la te d

i n ord er o f im portance.

1. A dhesion s e c t i o n in one c a se .

2. A com bination o f f a c t o r s i n fo u r te e n o th e r c a s e s . These were : -

(a ) C o lla p se by pneumothorax o f c a s e s u n s u i t a b le f o r trea tm en t by pneumothorax.

(b) ’F a i lu r e to a c h ie v e c a v i t y c lo s u r e w ith consequent spread o f u n c o n tr o l le d lu n g d i s e a s e to th e p leu ra . B r o n c h o -p le u r a l f i s t u l a may have occurred in one c a se from t h i s ca u se .

(c ) Development o f com plete a t e l e c t a s i s

(d^ E x te n s iv e ad h esio n s e c t i o n on u n h e a lth y p leu ra eand a d h es io n s .

( e '1 M aintenance o f in co m p le te or i n e f f e c t i v ec o l l a p s e - i n some c a s e s by p o s i t i v e i n t r a p le u r a l p r e s su r e s .

79

B i l a t e r a l Empyema.•

Three p a t i e n t s d ev e lo p ed b i l a t e r a l empyema.

D e t a i l s o f the s i x pneumothoraces in v o lv e d are

g iv e n in Table 4 5 .

TABLE 45

5 Cases o f B i l a t e r a l Empyema

CaseNo.


A .P .

E .S .R .a tin d u c t io n

Sta te o fPleuraa t

C avityc lo s e da f t e ra d

In t e r v a lfrom

I n t e r v a lfrompneumo

Mino fH e a lth .

S. & C. m.m.2 hrs(w. )

th o r a coscopy

h e s io ns s c t io n

i n d u c t io n t i l l pneumol y s i s ( Wks . )

l y s i st i l lempyema

(W ks.)

1 (L) RB3 11 68 nots t a t e d

No 7 18

(R) RB3 11 62 t t No No ope r a t ion : abandoned

14fromi n d u c t ion

2 (L)

(R)

RB2

RB2

8

8

39

37

U n h ea lth y white t h i c k , a s p ir a te c b e fo r e opn. H ealthy

No9

No

6

21

10

20

3 (L)

(R)

RB3

RB3

12

12

64

48

H ealthyt t

No

No

7

7

18mths • 14mths •

80

Remarks -

In e a c h case th e l e f t (L) pneumothorax

was induced f i r s t .

Case 1 : (L) s id e - fa r advanced a c t i v e d i s e a s e

a t in d u c t i o n . C o lla p se i n e f f e c t i v e . B r o n c h o -p le u r a l

f i s t u l a occurred from rupture o f an a p i c a l c a v i t y

18 weeks a f t e r a d h e s io n s e c t i o n .

(R) s id e - f a r advanced a c t i v e d i s e a s e a t

in d u c t io n o f pneumothorax, w hich was done f iv e - a n d - a -

h a l f months a f t e r in d u c t io n o f th e (L) A .P . and sev en

weeks b e fo r e the l e f t empyema d e v e lo p e d . C o lla p se was

i n e f f e c t i v e . T hick pus was a s p ir a t e d 14 weeks a f t e r

i n d u c t i o n . T h is empyema was due t o m a in ta in in g an

i n e f f e c t i v e c o l la p s e w i th s t r e t c h i n g and p o s s i b l e t e a r in g

o f m u lt ip le a d h e s io n s , and f a i l u r e t o g e t c a v i t y c lo s u r e .

Case 2 ; (L) s id e - m od erate ly fa r advanced ,

m o d era te ly a c t i v e a t in d u c t io n . P leura u n h e a lth y .

F lu id was removed a t o p e r a t io n . C o llap se i n e f f e c t i v e .

Cause o f empyema: Adhesion s e c t i o n on tu b e r c u lo u s p le u r a .

(R) s id e - M oderately fa r advanced , r e l a t i v e l y

in a c t i v e d i s e a s e a t in d u c t io n . Pneumothorax induced

3 months a f t e r the (L) A .P . and 6 weeks b e fo r e l e f t

empyema a p p eared . C o llap se i n e f f e c t i v e - d i s e a s e and

81

m u lt ip le c a v i t a t i o n u n c o n t r o l l e d .

Causes o f empyema:

1 . U n s u ita b le case for trea tm en t by pneumothorax,

2 , Spread o f u n c o n tr o l le d d i s e a s e t o p le u r a .

Case 5 : B i l a t e r a l f a r advanced a c t i v e d i s e a s e

a t i n d u c t i o n .

(L) - c o l l a p s e s a t i s f a c t o r y but c a v i t i e s not

c lo s e d a f t e r a d h e s io n s e c t i o n . E f f u s io n appeared one

week a f t e r o p e r a t io n - c le a r e d a f t e r one a s p i r a t i o n .

O leoth orax i n s t i t u t e d .

(R) - c o l la p s e i n e f f e c t i v e but m ain ta in ed by

o le o t h o r a x . Pure pus was a s p ir a t e d from b o th s id e s on

o c c a s io n o f f i r s t a s p i r a t i o n .

Causes o f empyema:

On th e (L) s id e - o le o th o r a x was induced a f t e r

an e f f u s i o n had o c c u r r e d . B ro n c h o -p le u r a l f i s t u l a from

o le o th o r a x appears t o have been the c a u s e , but was not

proved a s the p a t ie n t never spat up o i l or pus mixed w ith

o i l .

On the (R) s id e -

1 . C o llap se o f lung a f f e c t e d by a c t i v e d i s e a s e w i th m u lt ip le c a v i t a t i o n .

2 . Maintenance o f co m p le te ly i n e f f e c t i v e c o l l a p s e by pneumothorax and o l e o t h o r a x .

82

Four ca g es in whom Empyema did not d e v e lo p t i l l

a f t e r d is c h a r g e from S an ator iu m •

Four c a s e s d eve lop ed empyema a f t e r d i s

charge from the Sanatorium , and w h ile a t te n d in g t h e i r

r e s p e c t i v e t u b e r c u lo s i s c l i n i c s f o r pneumothorax

r e f i l l s •

Three p a t i e n t s were r e -a d m it te d w i t h empyema

o f i n d e f i n i t e d u r a t io n 2 y e a r s and 8 m onths, 3j- y e a r s ,

and 4-J- y e a r s from th e date o f a d h e s io n s e c t i o n .

One case was not r e - a d m it t e d , but i s known to have

d ev e lo p ed empyema 2 y e a r s and 8 months a f t e r o p e r a t

io n f o r a d h e s io n s e c t i o n .

I t i s not su g g e s te d th a t a d h e s io n s e c t i o n

had any b ea r in g on th e developm ent o f empyema in

th e se c a s e s , but the o n se t o f empyema i s dated

from o p e r a t io n fo r the sake o f u n ifo r m ity w i t h the

p r e v io u s c a s e s .

D e t a i l s o f th e se c a s e s are g iv e n i n Table

f

83

TAB LI 46 • 4 Ca se s

CaseNo.

C l a s s i f i c a t i o n o f d i s e a s e a t in d u c t io n o f pneum othorax.

E .S .R .a tin d u c t io n . m ,m.2 h r s . (W.)

S ta teo fPleuraa tth o r a cosco p y

C avityc lo s e da f t e rpneumo l y s i s

Typeo fc o l la p sea f t e rpneumo l y s i s

I n t e r v a l from pneumo l y s i s t i l l se r o u s e f f u s - ion(Weeks

Min.o fH ea lth

S.& C.

1 RB2 6 38 H ealthy No Incomp le t e

wfcd F lu id \ 2 r t o 5 th c o s ta 1 c a r t .

2 RB2 6 38 Nots t a t e d

No u F lu id (5}-to 4 th c o s t a l c a r t .

3 RB2 11 91 Unh e a lth y

Yes Comp le t e

F lu id (3j*to 4 th c o s t a l c a r t .

4 RB2 11 47 Inflamedred

No !f N il

Remarks -

Case 1: T his p a t ie n t had o n ly moderate d i s e a s e

w i t h moderate a c t i v i t y a t in d u c t io n . C o lla p se was

in c o m p le te . Sputum p o s i t i v e a t d i s c h a r g e .

Cause o f empyema -

1 . M ain ta in in g in com p lete c o l l a p s e .

2 . F a ilu re to a c h ie v e c a v i t y c lo s u r e and c o n v e r s io n o f sputum.

84

Case 2: S im ila r to Case No, 1,

Case 3: T h is p a t i e n t had advanced a c t i v e

d i s e a s e a t in d u c t io n . E f f u s io n d ev e lo p ed a f t e r

a d h e s io n s e c t i o n , but a b so r b e d . C o lla p se m a in ta in ed

by o le o t h o r a x .

Cause o f empyema: Not known - may have been b ron ch o

p l e u r a l f i s t u l a from e f f e c t o f o l e o t h o r a x .

Case 4: F&r advanced d i s e a s e , b u t moderate

a c t i v i t y a t in d u c t io n .

Causes o f empyema - S im ila r to Case No. 1 .

85

Ca s e s o f Pneumothorax and Empyema in w h ich No A dhesion

Sefction was d o n e .

Seven c a s e s o f pneumothorax were not su b

m it t e d t o a d h e s io n s e c t i o n . Five o f th e se were

in s p e c t e d by th o ra co sco p y and th e a d h e s io n s were

found t o be in o p e r a b le . One o f th e s e c a s e s d ev e lo p ed

b r o n c h o -p le u r a l f i s t u l a and has been c o n s id e r e d

under c a s e s in t h a t c a te g o r y .

Two c a s e s o f pneumothorax were abandoned

b e fo r e i t was p o s s ib l e to in s p e c t t h e i r a d h e s io n s

b eca u se empyema had a lr e a d y d e v e lo p e d . One o f

th e se pneumothoraces was in a p a t i e n t who d ev e lo p ed

b i l a t e r a l empyema and has been c o n s id e r e d w ith th e

b i l a t e r a l empyemata.

Five c a s e s remain fo r c o n s id e r a t io n now.

Four c a s e s o f Pneumothorax and Empyema sub m itted t o

Thoracoscopy o n l y ,

D e t a i l s o f th e s e c a s e s are g iv e n in Table 47,.

86

TABLBJ 47 4 C ases

CaseNo.

C l a s s i f i c a t i o n o f D is e a se a t In d u c t io n o f

A .P .

E .S .R .a tin d u c t ion

S ta teo f

■ Pleura a t


I n t e r v a l from th o r a -

Min.o fH ea lth

S. & C. m.m.2 hrs(W.)

t h o r a c o s cop y .

iont i l lt h o r a c o s copy

(Weeks)

c o s -copyt i l lempyema

(Weeks)

1 RB2 5 38 Angryred

7 1

2 RB2 5 50 Nots t a t e d

12 4

3 RB2 11 88 Unh e a l th y w h i t e , a s p i r a te d once •

16 1

4 RB2 10 90 Red and in flam ed

8 10

Remarks -

1 . A l l c a s e s had i n e f f e c t i v e c o l l a p s e .

2 . A l l pneumothoraces were abandoned immed

i a t e l y a f t e r a d h e s io n s were found t o be not d i v i s i b l e .

Causes o f Empyema in th e se Cases -

1 . In d u ct io n o f pneumothorax in the p resen ce o f a c u t e l y a c t i v e a n d /o r fa r advanced d i s e a s e , 2 c a s e s .

2 . Maintenance o f i n e f f e c t i v e and u s e l e s s c o l l a p s e . . ,in a l l c a s e s .

87

One case o f u n i l a t e r a l pneumothorax was

abandoned b e fo r e th o ra co sco p y cou ld be p erform ed .

T h is p a t i e n t had a pneumothorax induced

w h ile s u f f e r i n g from a c u te tu b e r c u lo u s pneumonia.

The c o l la p s e was q u i t e i n e f f e c t i v e . Pus was

a s p ir a t e d on the o c c a s io n o f the f i r s t a s p i r a t i o n

11 weeks a f t e r in d u c t io n o f the pneumothorax.

Cause o f empyema was in d u c t io n o f pneumothorax

during a c u te tu b e r c u lo u s pneumonia w i th ra p id p le u r a l

in vo lvem en t •

PART 3

88.

TREATMENT AND RESULTS

I s h a l l now p r e s e n t the r e s u l t s o f the

d i f f e r e n t ty p e s o f trea tm en t used in th e e ig h ty - o n e

empyemata. For the purposes o f t a b u la t io n the

c a s e s o f "pure" not p y o g e n ic a l ly i n f e c t e d empyemata

w i l l be termed Group A, and th ose s e c o n d a r i ly i n f e c t

ed w i l l be termed Group B . T h ir t y - f o u r (43.6%) o f

th e 78 p a t i e n t s had empyemata w hich became i n f e c t e d

w i t h p y o g en ic organ ism s, but a s one p a t i e n t w ith

b i l a t e r a l empyema had b o th s id e s s e c o n d a r i ly

i n f e c t e d , t h i r t y - f i v e (43.2%) o f the 81 empyemata

f a l l in t o Group B .

To o b v ia te c o n fu s io n in th e p r e s e n ta t io n

o f the r e s u l t s , i t was c o n s id e r e d w is e r t o d e a l

f i r s t w ith th e f i f t y c a s e s o f u n i l a t e r a l pneumothorax

and empyema; s e c o n d ly , w i th the t w e n ty - f iv e c a s e s

o f b i l a t e r a l pneumothorax and u n i l a t e r a l empyema;

and th ir d . ly , the th ree c a se s o f b i l a t e r a l empyema.

W hile t h i s n e c e s s i t a t e s some degree o f r e p e t i t i o n

in th e T a b le s , i t a v o id s c o m p lic a t io n s in d e a l in g

w ith the th ree b i l a t e r a l empyemata, where one p a t i e n t

had d i f f e r e n t trea tm en t used on ea ch s i d e , an d the

o th er two p a t ie n t s each had one empyema f a l l i n g

in to Group a , and one f a l l i n g in to Group B.

89.B efore p ro ceed in g to p r e s e n t d e t a i l s o f

the type of trea tm en t used and th e s u r v iv a l o f

th e p a t i e n t s concerned in e a c h Group, a summary

o f c a s e s o f tr ea tm en t and o f s u r v iv a l i s g iv e n

in th e T a b les 4 8 , 4 9 , 50 and 5 1 .

Seven d i f f e r e n t ty p e s o f trea tm en t were

em p loyed . These are g iv e n as c o n t r a c t io n s in

the T a b le s and t h e i r com plete d e s c r i p t i o n i s g iv e n

h e r e . A, D, and L .S .O . in the T a b les mean A l i v e ,

Dead, and Lost S ig h t O f, r e s p e c t i v e l y .

The trea tm en ts used were a s f o l lo w s : -

1 . Simple a s p i r a t i o n and a i r r e p la c e m e n t .

2 . Lavage w i th Azo T. s o lu t i o n a f t e r a s p i r a t i o n .

3 . A s p ir a t io n fo l lo w e d by lavage w ith Azo T and com b in ation s o f Azo T., normal s a l i n e , e u s o l , m ethylene b l u e , Carre 1-Dakin s o l u t i o n , e t c .

4 . A s p ir a t io n o n ly or combined w ith Azo T. and s a l i n e la v a g e , p lu s sulphonamiae powder or p e n i c i l l i n i n t r a - p l e u r a l l y .

5 . A s p ir a t io n , lavage w ith Azo T., s a l i n e , e t c . and f i n a l l y c lo s e d dra inage by s e I f - r e t a i n i n g c a t h e t e r .

6 . O leo th o ra x .

7 . T h o r a c o p la s ty .

90 01

ooh 4

FQ<rjEH

to43P0

•H-PcdPh

00

-PP

I-Pcd©PEH

ftO

TOHftGO0ft

-PP0P

-Pcd©PEH

ft W O 0 I rH • TO

O cd O cd Eh 43 S O

ft ra O 0I rH • 00

O cd O cd [h P S O

ftftoftC±3 ft TO O 0

I i—1 • GOO Cd O Cd R 43 S O

■Paft 0 o £ -p

© cd ft 0 > s P Eh Eh

to

to(—I LO 00 to

o o rH

J>- H4 rH

LO t o tO ft-

to03

rH I—I 03rH

03 O O O O

H4 t o tO ft- 03 H

O O rH 03 03

CD 03 H 4 CD><

CO H4 H4

i—1 O O O

05 H4 lO 03

ft- tO 03 to tO

ft-rH

05 00

f t f t HP P ocd cd ,

1 ,P ,P PP 0 P 43 * P 43 OO P 43 O H H O «H *H m•H C •H £: O •H «g 43 P43 P 0 43 TO 43 cd Ocd *rl S cd 0 Cd 0 P r iP cd © P roOR P fcD *H 43•H O •H cd •H cd ft ftP)ft cd P, > o f t > g rHTO ft rH TO cd N TO cd O O<r| cd Pi <h rH <d rH O TO

o toI

0r. r0

ft ft *HO ft £ cd cd

ft 0 o hO«P cd P- > H ftTO

•Hft I 0 cd P, ft

-PP. ft O *H

ro cd<ri rH

ft ft0 »Hf t rH ■g rH _ O H H ftO P,

1>5 I—I rH Cd ft ft 0

rH------ P --------

P♦H 0f t bo

T' alf t f t C XO P *H cd•h cd <d P43 f t Ocd 0 f t SP fciQ 43•H cd 0 Of t > JQ a)0 cd > 1—1

< ! H 4 ) 0

LO

PTOcdHftOocdfto-pEh

VS,ft-

CD

VCi—I •

to LO H4 LO

03 05 •03 ft-

tO

COft- —' - —€8-

H 4'

i—I rH

CD

ft-tO P 03

CD

ft- O03

H4t o

LO

03 H4

O LO 03 H4

03 a 03 LO

H4H4

i—Icd43OR

rHcd • *SP X0 cd

43 P t>3cd 9 f trH f t•H 4 3 ©£3 O f t

•P 0 *H rH TO

43 O•H 43£ • 5>>ft

43f t tiO

•HP TO P0 0

•H f t 043 •H f tcd TO 43f t

0rP P 43 O

P OO f t f t

0p

P cd 1f t Of t 0

H f t f tO 0 »H •P 43 TO P

•H cd °

P0 43 .H p f t 43

43 0 f tO•H • 1—1 1—143 P 0 0cd O - P 0 TOP vH O f t•H 43 43 Rf t cd •»G l P cd P °cd *H £ O N

f t 0> 3 TO I>j K .

r-Q Cd f t Cd rP

•O >3£ p 43 0 0 .H

© f t f t £43 <H 43cd 0 cd O 00 0 P 0 &CP f t 0 «H Cd

43 «iH 43 O >TO cd cd

m _ 1—l ft. 1—1f t •H f t

f t 43 f t rHft 0 , f t cdO rQ f t 0 PP 0 4 5 dcd P cd 0

0 TO 0 rHp 0 P ft)•h f t TO 43

0 cd VTO 43 O TO P0 cd _ cd cdTO 0 0 >cd P ^ p0 43 4 3 p 0

X ft 0 H0 f t 43

•rl £ ' d 43 cdTO 0 p o p

> 3 rH »H0 ft) f t 0 ft.

f t £ P f t TOR 0 H 43 cd

92

Table 48 shows t h a t o f the s e v e n t y - e ig h t

p a t i e n t s who d eve lop ed empyema, e i t h e r "pure" or

"mixed” t y p e , f o r t y - t h r e e are dead (55.1%) and

tw e n ty -n in e (37.2%) are a l i v e . S ix p a t i e n t s (7.7%)

were l o s t s ig h t o f . The p er iod o f s u r v iv a l was

a t th e lo n g e s t 1T | y e a r s , and a t th e s h o r t e s t 3-J y e a r s .

The f ig u r e s in Table 48 in c lu d e a l l c a s e s

o f empyema, whether in u n i l a t e r a l or b i l a t e r a l

pneum othorax. W ith any type o f trea tm en t one

cou ld assume th a t the c a s e s o f b i l a t e r a l pneumothorax

w it h u n i l a t e r a l empyema w i l l fa r e -worse than c a s e s

o f u n i l a t e r a l pneumothorax and empyema, w h ile c a s e s o f

b i l a t e r a l empyema w i l l fa re worst o f a l l .

T ab les 4 9 , 50 and 51 show trea tm en t and

s u r v i v a l o f the f i f t y c a s e s o f empyema in u n i l a t e r a l

pneumothorax and in the t w e n ty - f iv e c a se s o f

u n i l a t e r a l empyema in b i l a t e r a l pneumothorax.

Group A and Group B c a se s a re shown s e p a r a t e l y .

Table 49 shows the r e s u l t s when Groups A and B are

combined.

93

a

aPQ<UEh

P

HHHOWcd <d+3 • Wo o cd^ 3 0

H Ocd<4-3 •O O

W <D WcdEh ^ O

P

H Ocd-P •o o

w <D WcdEh SS O

G1-Pcd©PEH

CO

LO

03H

CD

O

LO

CO

CD

COLO

o

LO

O H

03 H

03 £>

03

03

O

03

H

O

CO

H

O O H

LO

o

H H

O 03

CO

O O O

CO CO CO H O

03 03 LO

CD lO

go

•H+3cdP•HPto<d

08GO•rH-PcdP W)Eh

cd> o

w cd N<d h <tj

P

- r r -09-G O

,G HG -P -Po h oH £ H -P O cd © wP bC • •H cd P p > e w cd O

< J H O

gcd

-*©- O I > O CO LO

G »© © cd

W t l P< PG 0 H O H g

•H O cdC© O p ©

cd P P H P H £ H

3 O H H w P o P

+3cdPi

•HP

-P P G O H Hi—I

G cd ■H p

O ©W cd

<t| H

i—«d--------- P - iH i —I p

cd•* G p

G H © HIO P TO cd

H O P-P p rH ocd G o P iP cd -p

•h <d oP © p ©w bC O rH

<d cd -P O

-PTOcdHpoocdPoPiE-'

iO03

03

OLO

P

P i—I

0303

Oi—I

P- i—I

00J£L

Hcd-PoEh

94Of th e t o t a l o f f i f t y p a t i e n t s , tw en ty -on e

(42$) are a l i v e ; t w e n t y - f iv e (50$) are d ea d , and

fo u r (8$) are l o s t s ig h t o f .

Of th e tw en ty-on e a l i v e , s e v e n te e n (8 0 .9 $ )

were in Group A and four ( 1 9 .1 $ ) in Group B.

Of th e t w e n t y - f iv e dead , a t o t a l o f f i f t e e n

(60$) were in Group B and te n (40$) in Group A.

One o f the .Group B c a s e s l o s t s i g h t o f was known

t o have su r v iv e d a t l e a s t th ree y e a r s .

D e t a i l s o f the trea tm en t o f th e se Groups

are g iv e n l a t e r .

95

oLO

aPQ

Eh

P

rH *Hcd o+3 • O OEh

P

I—I <+-f GO Cd O 0p • mO o CSEH J25 o

IO

P

i—I Ph co aJ O 0 p • ro O O al

-PPI

g+3cd©UEh

O H

rH

to

O tO rH

O

tO CM CM

CM t o

CM O

to o

O H o o o o

H O CM CM O

O O O O rH O

rH i—I CM to O

o o o o o

CO rH CM O

O O O O

03 CM to o

PIO Eh

1 •Hp P ocd cd NPi Pi <d

•H •HOh Pi a dCO O TO PI

*h <tj cd

PJO go

•H PI +3 • O cd O *rl P» S -P

•rl O S f t O H m O <d <£3 ra

j-ft i_£~L

Pi 0 rHO tS *HP ^ Oa o *h

h a pi p> ©M OH 0 ft cd d

a > d *h dra cd PI S PI

<d rH cd cd cd

PI o•H•P cd 0 P.•rH

O rH ■«d-

CM O

- PI PI *rH

W cda c

•H *iHp •> cd cd 0 Pi Pi fctOd

■H cda > •TO cd rH<r! i—I O

XcdP)OPPo© I—Io

Io o N cd pPi mO cd

P rHeh a

9 6

Of t h e t o t a l number o f t w e n t y - f i v e c a s e s ,

s i x t e e n (64$) were i n Group A and n in e (36%) were

i n Group B. S i x t e e n (65$) o f t h e t w e n t y - f i v e c a s e s

a r e d e a d ; s e v e n (28$) o f t h e t w e n t y - f i v e a r e a l i v e .

Ten o f t h e s i x t e e n i n Group A, e q u a l t o 6 2 .5 $ a r e

d e a d , and f i v e , e q u a l t o 3 1 $ , a r e a l i v e . S ix o f t h e

n in e c a s e s i n Group B, e q u a l t o 6 6 . 6 $ a r e d e a d , and

tw o , e q u a l t o 2 2 . 2 $ , a r e a l i v e .

The n l o s t s i g h t o f ” c a s e i n Group B was

known t o have s u r v i v e d 5 i y e a r s .

T h ree c a s e s o f B i l a t e r a l Empyema.

Case 1 had b o t h empyema s e c o n d a r i l y i n f e c t e d .

He was t r e a t e d by a s p i r a t i o n o n ly on b o t h s i d e s .

He i s d e a d .

Case 2 had one empyema s e c o n d a r i l y i n f e c t e d

and t h e o t h e r n o t . He was t r e a t e d by o l e o t h o r a x on

b o t h s i d e s . He i s a l i v e .

Case 3 h a d . s e c o n d a r y i n f e c t i o n on one s id e

and one r e m a in e d f r e e from s e c o n d a r y i n f e c t i o n . She

was t r e a t e d on t h e s i d e n o t s e c o n d a r i l y i n f e c t e d , by

a s p i r a t i o n o n l y , anci on t h e s e c o n d a r i l y i n f e c t e d s i d e

she had an o l e o t h o r a x . She i s a l s o d e a d .

F u r t h e r d e t a i l s o f t h e s e c a s e s w i l l be g i v e n

l a t e r .

97

LO

S3PQttEh

to0TOCd

O

0>£

+3a0>0

CO

fto

I—Icd>•H>PdCO

ttS3cd

ftS38-pcd0PEh

t t0S3•H

HOO

TO0TOcdo

PQt tS3cd

ftdoPt t

d.

t t S3 cd

TO 0 O cd PO .

0+3 l>.O fte 0d Kj 0S3 H

f t cd P

<H 0 cd -P P cd 0 tt -P -H cd S3 t t t t •rH ftLO03

TO0Ocd

8tt!-poS cd=5 £ 0 0 S3 >5ft ft

st t f t cdP t t 0 S3

f t cd

S3t toLO

cCO

ttl

t tcd0ft

H ft TO cd O 0 4-3 • TOo o cdft tt o

oCO

ft

t tcd0ft

0>•HrH•tt

u * .i—I ft TOcd O 043 • TOo o cdft tt o

ftc

ft 0 o g

-p0 cd p^ 0 1>> P f t f t

o o O O O

ft CO 03 03

CO O 03 O

OrH

CO 03 CO CO O

CO O O O O O H

uo LO CO LO 03

t t t t CO I—1 O 03 c -

03f t

p•Hcd

t tS3cd

4-3 S3 S3 C 0 •H £ -P 0 cd o P cd •H rH P , P i TO 0

t t P

00 00

0Eh tn to

Cd S3o > ON cd *Ht t rH ft

dt t t t 1—1S3 S3 ccd Cd n

S3 S3 •C ° £•rH .H £4-*’ f t ccd 0 cd oP W P•H cd •H t tft > P f tcn Cd TO •(-!t t ft t t

t t LO t t ft

0Wcd> t t cd S3

rH Cd

t t S3 S3 .H

01SS3 »Hc o

•H *Hf t S3 cd 0 P p , •Hp .- t tTO P

•tt cd

PCDtt'<5 ft.P , f ti—i0 cd ' t t p •h d £ 0 cd t t S3 f t Ot t! cd ft, p i—i ftd S3TO *H

HcdS3•HftttS3 0cd Ed)

cdS3 S3 WO .H cd

•H cd Pft P ocd tt tt!P 4-3

•H 0 OP ,t t 0to d rH

tt ft c

ftftTOcdrHftOOcdPott!Eh

•SS-03

■ttLO

CO

\ t t0303_

f t

LO03

00

t t

•VHOLO

LO03

03 t t

rH03

OLO

i—IcdftoEh

98

DETAIllS OF TREATMENT

The f o l l o w i n g T ab les g iv e d e t a i l s o f th e

d i f f e r e n t ty p e s and d u r a t io n o f trea tm en t employed in

f i f t y c a s e s o f empyema i n u n i l a t e r a l pneumothoraces and

i n tw en ty f i v e c a s e s o f u n i l a t e r a l empyema i n b i l a t e r a l

pneum othoraces- The th r e e c a s e s o f b i l a t e r a l empyema

w i l l be c o n s id e r e d s e p a r a te ly .

S u r v iv a ls and d eath s o f p a t i e n t s are p r e s e n te d

g r a p h ic a l ly on p ages 115 and 116 and f o l lo w in g page 117.

S even ty F iv e Empyemata

Treatment

1. The s im p le s t method o f trea tm en t i s by a s p i r a t i o n

fo l lo w e d by a i r rep la cem en t.

TABLE 52

Twenty-two c a s e s were t r e a t e d by t h i s method.

U nil a t e r a l A. P. and empyema.

'Group A - 8 Cases

Case D u ra t io n o f F ate o f P a t ie n t S u r v iv a l a f t e rN o. Treatment S t a r t o f Empyema.

Months

1 6 A liv e ; working 7 y e a r s 6 months2 2 If u 5 y ea r s3 k tt ti 8 y ea rs 6 monthsk 11 t» l» y ea rs5 1 Dead not known6 3 Dead 5 v months7 1 L ost s ig h t o f not known8 1 Dead 7 y ea rs

99Thus i n t h i s group o f e ig h t c a s e s , four

are a l i v e , w e l l and w orking; th r e e are d ead , and

one i s l o s t s ig h t o f . T his l a s t case was known

t o be a l i v e th r e e yea rs a f t e r empyema b egan .

A s p ir a t io n o n l y .

TABLE 53

Group B - Four c a s e s U n i l a t e r a l A .p . and Empyema.\jri.

Case D u ration o f

O w J.AJ. J-WU u VS -1. - - • X • u* AiU.

Fate o f P a t ie n t

m w*. •

S u r v iv a l a f t e rNo. Treatment • s t a r t o fG Months empyema

1 24 Dead 10 y ea rs 3 months .2 2 Lost s ig h t o f Known t o have

su r v iv e d 3 yearsth en l o s t s ig h to f .

3 1 Dead 1 month a f t e rs p o n t . pneumoth orax .

4 1 Lost s ig h t o f Not known.

Of four c a s e s i n t h i s s e c o n d a r i ly in f e c t e d

g ro u p , two are known t o be dead and two are l o s t s ig h t

o f - f a t e unknown.

TABLE 54

Group A - 9 c a s e s B i l a t e r a l Pneumothorax: U n i la t e r a l _________________ Empyema ______________

CaseNo. D u ra tio n o f

T rea tm en t. Months .

■ AT ....... .. —

Fate o f P a t i e n t . S u r v iv a l a f t e r s t a r t o f empyema

1 4 Dead 4 y ea rs2 3 A l iv e ; not w e l l 4 years 8 months3 4 Dead 1 year 7 months

100TABLE 54 (C o n t in u e d )

CaseNo.

D u ra t io n o f Treatm ent •

Months


4 5 Dead: contra l a t e r a l spon . pneum.

3 y ea rs 1 month

5 2 A l iv e : working 4 y ea rs 6 months6 1 Dead: contra

l a t e r a l s p o n t . pneum. 1 year

7 1 Dead 4 y ea rs 6 months8 6 Dead 10 y ea rs 6 months9 23 A l iv e ; working 7 y ea rs 6 m onths.

In th e case o f the two men a l i v e , w e l l and

w o rk in g , one (No. 5 ) had h is pneumothorax con tin u ed

on th e empyema s id e fo r y e a r s ; th e o th er (No. 9)

had h i s pneumothorax con tin u ed a f t e r empyema fo r

4 y e a r s and 2 m onths.

TABLE 55

G-roup B - 1 case B i l a t e r a l Pneumothorax: Uni l a t e r a l _____________ Empyema_________________________

CaseNo.

D u ra tio n o f T rea tm en t.

Months •

........................................ ..............................■ ■ ■ ■ ■


1 2 Dead 7§ m onths.

This p a t ie n t g o t a spontaneous pneumothorax

4 weeks a f t e r a d h e s io n s e c t i o n ; the pneumothorax

was th e n abandoned.

i . T r e a tm e n t by As p i r a t i o n and la v a g e j / i t h AzoT. So l u t i o n .

E l e v e n c a s e s were t r e a t e d s o l e l y "by t h i s method.

TABLE 3_6

Group A - 7 C a s e s - U n i l a t e r a l P n e n m o t h o r a c e s ______________

CaseNo.

D u r a t i o n o f T r e a tm e n t

Months

P a t e o f P a t i e n t S u r v i v a l f rom o n s e t o f empyema

1 3 A l i v e ; w o rk in g U y e a r s 8 months

2 5 Dead 2 3/ e a r s 6 months

3 11 Dead 2 y e a r s 2 months

k ' 3 A l iv e * w o rk in g 8 3/ e a r s 3 months

5 20 A l i v e ;w o rk in g 1+ 3/ears

6 5 Dead 3 3/ e a r s

7 8 A l i v e ;w o rk in g 5 3/ e a r s 2 months

Of s e v e n c a s e s i n t h i s g roup , f o u r a r e a l i v e , w e l l and

w o rk in g a f t e r a ' c o n s i d e r a b l e p e r i o d from o n s e t o f empyema

t h r e e a r e dead .

Group B - One c a s e

CaseNo.

D u r a t i o n o f T re a tm e n t

Months

P a t e o f P a t i e n t S u r v i v a l f rom o n s e t o f empyema

1 2h(12 as ou t

p a t i e n t )

Dead 3 y e a r s

102

TABLS 57

Group A - 2 c a s e s B i l a t e r a l Pneum othorax: U n i la t e r a l _______________empyema_________________ _______________

Case D u ra tio n o f pate o f P a t i e n t . S u r v iv a l a f t e rNo* T re a tm en t . s t a r t o f

M onths. empyema

1 7 A l iv e : working 6 years2 18 Dead 2 y ea rs 4 months

Case No. 1 g o t a spontaneous pneumothorax

th ro u g h a p leu ra studded w ith t u b e r c l e s one week a f t e r

a d h e s io n s e c t i o n . 'The pneumothorax vms abandoned

10 months a f t e r the b r o n c h o -p le u r a l " f i s t u la o c c u r r e d .

Thus she has l i v e d so fa r 5 y ea rs ana one month

a f t e r th e pneumothorax was abandoned.

Group B - 1 c a s e .

3aseNO.

D u ra tio n o f T re a tm en t.

Months •

pate o f P a t i e n t . S u r v iv a l a f t e r s t a r t o f empyema .

1 6 Lost s ig h t o f . Known t o have su r v iv ed5 years 10 months

T h is p a t ie n t g o t a spontaneous pneumothorax

th rou gh a ruptured t e n s io n c a v i t y 10 weeks a f t e r

a d h e s io n s e c t i o n . Her pneumothorax was abandoned

15 months a f t e r empyema appeared .

105

3 (a ) Treatm ent by A s p ir a t io n and lavage w ith com b in ation s

o f Azo T , normal s a l i n e , j S u s o I , C arre l-D ak in S o lu t io n ,

e t c •

S ig h t c a s e s were t r e a t e d by th e above methods

TABL3 58

LTA ' - / U p

CaseNo.

jn. — v w . —

D u ra tio n o f T r e a tm e n t .

Months •

Fate o f P a t ie n t • S u r v iv a l a f t e r s t a r t o f empyema

1 11 Dead ( s p o n t . 2 y ea rs 4 monthspneum .)

2 5 Dead 5 yea rs 6 months3 7 A liv e (T .B . Hip

now) 10 y ea r s4 1 Dead 4 y ea rs5 5 A liv e and work

ing 10 y ea r s j

In t h i s group o f 5 p a t i e n t s , th ree are dead

and two a l i v e , one o f whom i s w e l l and w ork in g . The

o th er has a tu b e r c u lo u s h ip j o i n t .

Group B - 5 c a s e s

CaseIMo.

D u ra t io n o f Treatment •

Months •

Date' o f P a t ie n t • S u r v iv a l a f t e r s t a r t o f empyema

1 Ik Dead (m e n in g i t i s ) 2 months2 6 Dead 7J- months3 5 A liv e 11 y ea rs

In t h i s group o f th ree p a t i e n t s , two are dead

and one a l i v e . Case No. 2 go t a haemothorax a f t e r an

open pneum olysis which fo llo w e d two u n s u c c e s s fu l a ttem p ts

104

a t c lo s e d p n e u m o ly s is .

Case Mo. 3 i s a l i v e but i s v e r y i l l , and

r e q u ir e s h o s p i t a l t r e a tm e n t .

3 ( b ) Treatm ent by Azo T and normal s a l i n e lavage w i t h

a s p i r a t i o n .

Four c a s e s were t r e a te d by t h i s m ethod.

TA3L3 59

G-roup -A - 5 Cases B i l a t e r a l Pneumothorax: U n i l a t e r a l

CaseNo.

D u ra t io n o f Treatment

Mont hs

Kite o f P a t i e n t . S u r v iv a l a f t e r s t a r t o f empyema

1 2 Dead 7 years2 2 Dead 5 yea rs 8 months3 6 Lost s ig h t o f Not known


12 hours a f t e r a d h e s io n s e c t i o n . Her empyema appeared

th e n and the pneumothorax was abandoned.

CaseNo.

D u ra t io n o f T rea tm en t .

Months

Kite o f P a t i e n t . S u r v iv a l a f t e r s t a r t o f empyema

1 11 Dead 9 ye ar s

T h is p a t ie n t g o t a spontaneous pneumothorax

11 months a f t e r a d h es io n s e c t i o n th rou gh a ruptured b a s a l

c a v i t y . His A. P. was m aintained fo r 6 years a f t e r

i 0 5

t h i s . He d i e d 3 y e a r s l a t e r .

U. A s p i r a t i o n and Azo T. o r s a l i n e l a v a g e , p l u s i na l l c a s e s , i n s t i l l a t i o n i n t r a - p l e u r a l l y o f p e n i c i l l i n o r su lp h o n am id e powder.____________________________________

TABLE 60

Group A - ,1'To cases.* Group B - 6 c a s e s

Group B - b c a s e s - U n i l a t e r a l A. P. and Empyema.

Caseho.

Type o f T r e a tm e n t

D u r a t i o nMonths

P a t e o f P a t i e n t

S u r v i v a l f rom o n s e t o f empyema

1 Azo T . l a v a g e s u lphonam ide powder , 20g. m. i n s a l i n e

7 Dead 2 y e a r s 9 months

2 Azo T.& s a l i n e l a v . 7 0 ,0 0 0 u n i t s p e n i c i l l i

2n

Dead 7 months

3 Azo T. & s a l i n e l a v . ; 2 1 gms. s u lp h . powder

3 Dead [ s p o n t . pnei

5 months im. )

b A s p i r a t i o n o n ly ; 1 7 0 ,000 u n i t s p e n i c i l l i n

b A l i v e 3 i y e a r s

Of t h e f o u r p a t i e n t s i n t h i s g ro u p , a l l

s e c o n d a r i l y i n f e c t e d c a s e s , t h r e e a r e d e ad ; t h e p a t i e n t

s t i l l a l i v e has s u r v i v e d 3 i y e a r s . The su lphonam ide powder

106

i n t r a - p l e u r a l l y was used a g a in s t s t a p h y l o c o c c i ,

s t r e p t o c o c c i and pneumococci i n one c a s e , and\

s t a p h y lo c o c c i i n the o th er c a s e , but was found t o

• have no e f f e c t on th e s e organ ism s.

TABL3 61

Group 3 - 2 c a s e s 3 i l a t e r a l A .p . U n i l a t e r a l Empyema.

CaseNo.

D u ra t io n o f T re a tm en t .

M onths.

Pkte o f P a t ie n t • S u r v iv a l a f t e r s t a r t o f empyema

1 83 0 0 ,0 0 0 u n i t s p e n i c i l l i n Dead 4 years

2 199 u n i t s p e n i c i l l i n Dead 7 months

Case No. 2 g o t a c o n t r a - l a t e r a l spontaneous

pneumothorax and d ied 4 weeks l a t e r .

107

5 # A s p ir a t io n , lavage w i th Azo T , s a l i n e , e t c . andf i n a l l y c lo s e d d ra in age by se I f - r e t a i n i n g c a t h e t e r .

TABLS 62

8 Cases - A l l Group B - U n i l a t e r a l A .P . and ECmpyemata.

CaseNo.

Type o f T reatm en t. D urationo f

DrainageTreatment

Months

Fhte o f P a t ie n t

S u r v iv a l a f t e r s t a r t o fempyema

1 Azo T , s a l i n e f l a v i n e , 15 c c . cod l i v e r o i l 6 Dead 1 yr 6 m th s .

2 F lav in e 1:2000 4 Dead 9 months3 Azo T , 31 gm.

sulphonamide powder i n cod l i v e r o i l

•6 Dead 8 months

4 Azo T lavage 3 Dead 11 months

5 Azo T lavage not known; done a s o u t p a t ie n t a f t e le a v in g Sana ium

Dead

rt o r -

5 yrs . 6 mths

A l l the p a t ie n t s in t h i s group are d ead .

The f i r s t four had b r o n c h o -p le u r a l f i s t u l a e a s the

cause o f t h e i r empyema.

108

TABLE 63

3 Cases - Group B - Bilateral A.P.; Unilateral Empyema.CaseNo.

Type o f T r e a tm e n t D u r a t i o n Months

A sp tn . TuBe.

F a t e o f P a t i e n t

S u r v i v a l f rom S t a r t o f Empyema

1 Azo T. l a v a g e 6 13 A l i v e 7 y r s . 6 mth£

2 Azo T. and S a l i n e l a v . 2 6 Dead 1 y e a r

3 Lavage w i t h s o t n . o f Methy l e n e B l u e : 2 5 c . c . l e f t i n c h e s t 1 6 Dead 11 months

6. O l e o t h o r a x

Twelve p a t i e n t s i n a l l were t r e a t e d By o l e o

t h o r a x . T h ree o f t h e s e p a t i e n t s u l t i m a t e l y came t o t h o r a

c o p l a s t y and a r e c o n s i d e r e d i n t h e g roup t r e a t e d By t h o r a

c o p l a s t y . Of t h e n i n e p a t i e n t s i n whom o l e o t h o r a x was t h e

f i n a l form o f t r e a t m e n t , f i v e came i n t o Group A and f o u r

i n t o Group B. Four p a t i e n t s had empyema i n u n i l a t e r a l

pneum othorax and t h r e e had u n i l a t e r a l empyema i n B i l a t e r a l

pneum othorax .

Two p a t i e n t s w i t h B i l a t e r a l empyema o f which

t h r e e empyemata were t r e a t e d By o l e o t h o r a x w i l l Be c o n s i d

e r e d s e p a r a t e l y u n d e r " B i l a t e r a l Empyema", (page 112) .

109

TABLE 64

Group A - 5 c a s e s U n i la t e r a l A. P. and Empyema.

CaseNo.

P r e l im in a r yTreatm ent

D uratio nMonths

O leo - t horax

D u ratio nMonths

Pateo fP a t i e n t

S u r v iv a l a f t e r s t a r t ofempyema

1 Azo T lav. 6 290 cc cod l i v e r o i l

2 A l iv e 7 yrs •

2 A s p ir a t io n on! ■7 1 35 c c . Gome no 1 1 Dead 8 yrs

2 mths •

3 Azo T . la v 6 35 c c . c od l i v e r o i l th en Azo T.

1 A l iv e 8 yrs .

Group B - 1 c a s e .

CaseNo.

P r e lim in a r y T re a tm en t .

Duratio n Mont hs

O leo- t horax

D u ratio nMonths

Pate o f P a ti e n t

S u r v iv a } a f t e r s t a r t o f empyema

1 Az o T la v p r o f la v in e 1 /1 0 0 0 , 3 7 5 ,0 0 0 u n i t s p e n i c i l l i n

2 225 cc cod l i v e r o i l

2 Dead 1 yr 4 mths

Of four u n i l a t e r a l empyemata t r e a t e d by o l e o

th o r a x , two are a l i v e and two d ead .

The case in Group B g o t a spontaneous pneumo

th orax and b r o n c h o -p le u r a l f i s t u l a one week a f t e r

c a u t e r i z a t i o n o f a d h e s io n s •

110

TABLS 65

B i l a t e r a l Pneumothorax: U n i la te r a l Empyema.

Two c a s e s , Nos . 1 and 2 are in Group A,

and o n e , case No. 3 , was i n Group B.

CaseNo.

P r e l im in a r yTreatment

Duratio nMonths

O leo- t horax

Durat -i o nMonths

FAteo fP a t i e n t

S u r v iv a l from s t a r t o f empyema

Group A1 Azo T lavage 2 695 cc

cod l i v e r o i l

7 A liv e 8 yrs .

2 Azo T lavage 5 95 cc cod l i v e r o i l

5 Dead 4 yrs .

GroufD B3 Azo T lavage

3 5 0 ,0 0 0 u n i t s p e n i c i l l i n

5 1,380 cc cod l i v e r o i l

21 A liv e 6-J yrs .


4 months a f t e r the o le o th o r a x had been in d u ced .

Case No. 2 g o t a c o n t r a - l a t e r a l spontaneous pneumothorax,

th e opening i n the p leura being observed a t t h o r a s o s c o p y .

7 * Thoracop la s t y

T h o r a c o p la s ty was performed in nine o f the

u n i l a t e r a l empyema c a s e s . Five c a se s were i n Group A

and fou r i n Group B. D e t a i l s o f th e s e c a s e s , w i th

th e trea tm en t used b efo re t h o r a c o p la s t y , are g iv e n

I l l

TA3LS 667 T h o r a c o p la s tyCaseNo.

Pre l i mi n a r y t r e a t m e n t be f o r eT h o r a c o p l a s t y

D u r a t i o n o f t h i s t r e a t ment

N o .o f R ibs

S u r v i v a l f rom o n s e t o f empyema

Croup A

1 A s p i r a t i o n o n ly 6 months 8 A l iv e 4 y e a r s

2 I! ff 6 weeks 7 tr 4-| y e a r s

3 n n 5 months 9 ff 8 y e a r s

4 Azo T l a v ag e o l e o t h o r a x 100 s cod l i v e r o i l

c9 months 10 ff 5 y e a r s

5 Azo T la v a g e 11 months 8 ff 3 y e a r s 9 months

Croup B

6 O l e o t h o r a x 37 cc Comeno1Closed D r a i n and A c r i f l a v i n e l a v .

1 month

20 months

10 Rost s i g h t o f

7 A s p i r a t i o n and l a v . w i t h h a l f - s a t u r a t e d s o l . u r e a .Azo T lav ag e O l e o t h o r a x o f 40 cod l i v e r o i l and 192,000 u n i t s p e n i c i l l i n

4 months . 1 month cc

3 months

7 A l iv e 4s y e a r s

8 Azo T and p r o f l a v i n e lav ag e 5 months 10 A l iv e 4 y e a r s

9 A s p i r a t i o n and c l o s e d d r a i n a g e 8 months

B a s a l4

T h o ra c o ,Dead 1 y e a r

7 months

112

Case 5 was done i n th e p resen ce o f f a i r l y

se v e r e c o n t r a - l a t e r a l d i s e a s e .

I t can be seen th a t o f the nine c a s e s sub

m it te d t o t h o r a c o p la s t y , sev en are known t o be a l i v e ,

w it h s u r v i v a l p e r io d s vary in g from 8 y e a r s t o th ree

y e a r s and n ine m onths. Three o f th e four s e c o n d a r i ly

i n f e c t e d c a s e s are a l i v e .

B i l a t e r a l Smpyema

Three p a t ie n t s s u f f e r e d from b i l a t e r a l

empyema. The trea tm en t i n th e s e c a se s was a s f o l l o w s .

The l e f t pneumothorax was induced f i r s t i n e a c h c a s e .

TABL3 67

Case 1 - Group B (b o th empyemata) .

CaseNo.

Type o f Treatment D uratio no fTreat -mentMonths

pate o f P a t ie n t

S u r v iv a l from s t a r t o f empyema

1 L .s id e : a s o i r a t i o o n ly

i7

1 year 2 months a f t e r L. empyema

R .s id e : a s p ir a t io ] o n ly . A .P . abandoned b efo re a d h e s io n s e c t i o n .

a

1 Dead

ll-g- months a f t e r R. empyema

This p a t ie n t g o t a spontaneous pneumothorax

113

on t h e l e f t s i d e f o u r and a b a l f months a f t e r a d h e s

i o n s e c t i o n .

Case 2 . T h i s c a s e had a s e c o n d a r y i n f e c t i o n on

t h e l e f t empyema o n l y .

CaseNo.

Type o f T r e a t m e n t . D u r a t i o no fT r e a t ment M o n th s .

Fate o f P a t i e n t

S u r v i v a l from s t a r t o f empyema

2 L. s i d e : Azo T l a v age and cod l i v e r o i l o l e o t h o r a x 290 c . c .

R . s i d e : Azo T l a v - age

8 months

4§ "

6 months

Dead

4 y e a r s a f t e r s t a r t o f L.

3 y e a r s a f t e r R. '

Case 3 . T h i s c a se had a s e c o n d a r y i n f e c t i o n o f t h e

r i g h t empyema o n l y . B o th empyemata were t r e a t e d by

o le o t h o r a x .

CaseNo.

Type o f T r e a t m e n t . D u r a t -i o no fT r e a t ment M onths•

Fate o f P a t i e n t •

S u r v i v a l from s t a r t o f empyema

3 L. s i d e : Azo T l a v a g e , 65 c c . cod l i v e r o i l

R. s i d e : Azo T and T u s o l l a v a g e •Cod l i v e r o i l 2 ,3 0 0 c c .Tube d r a i n a g e

17

8

52

A l iv e 6 y e a r s - s t i l l h av in g o c c . a s p i r a t i o n on R. s i d e .

t im eT h i s p a t i e n t i s f a i r l y w e l l and i s do ing p a r t

is? or k .

114

S u r v i v a l s i n s e v e n t y - e i g h t P a t i e n t s *

Of t h e t o t a l number o f s e v e n t y - e i g h t p a t i e n t s ,

t w e n t y - n i n e ( 3 7 .2 $ ) a r e known t o be a l i v e and have

s u r v i v e d p e r i o d s r a n g i n g f rom 11 t o 3-J- y e a r s f o l l o w i n g

o n s e t o f empyema. L e n g th o f s u r v i v a l f rom o n s e t

o f empyema i s known d e f i n i t e l y i n t w e n t y - e i g h t o f

t h e s e p a t i e n t s .

F o r t y - t h r e e p a t i e n t s ( 5 5 .1 $ ) a r e known

t o be d e a d . L e n g th o f s u r v i v a l f rom o n s e t o f empyema

i s known i n f o r t y o f t h e s e p a t i e n t s .

S ix p a t i e n t s were l o s t s i g h t o f t h r o u g h

r e c o r d s h a v in g b e en l o s t or d e s t r o y e d , b u t two were

known t o have s u r v i v e d p e r i o d s o f 5-J- and 3 y e a r s

r e s p e c t i v e l y .

The g r a p h s shown on t h e f o l l o w i n g pages

show t h e s u r v i v a l and d e a t h r a t e s f o r b o t h u n i l a t e r a l

and b i l a t e r a l pneum othorax c a s e s combined and f o r

u n i l a t e r a l and b i l a t e r a l pneum othorax c a s e s s e p a r a t e l y .

115

Deat h s - Graph No. 1 b e lo w shows t h a t w i t h i n s i x months

o f o n s e t o f empyema ab o u t 10$ o f t h e f o r t y p a t i e n t s had

d i e d ; w i t h i n t h r e e y e a r s 60 $ had d i e d ; by s e v e n y e a r s

9 0 $ were dead .

S u rv i v a l s - R e g a r d i n g t h e t w e n t y - e i g h t c a s e s i n which

s u r v i v a l i § k n o w n . i t i s s e e n t h a t 100$ s u r v i v e d t h r e e

and a h a l f y e a r s , 50$ f o u r and a h a l f y e a r s , a n d a l i t t l e

o v e r 10$ h a v e , s o f a r , s u r v i v e d more t h a n t e n y e a r s .G r a p h N o . 1

F r A P r E n R f R nn/ UtfiL.ft'TeR.nL. a ^ g £l l L A . P . C a s e s

4 0 C o-SC -S v

2 .8 C o t s e s

-

n)l%tcK h <x.\Je . d L ie .1

tK. K.cu/«. s u r v /n i e.cL

. . . . . . 7

Ro-

8a,

7o.mn.m2.

I

• --- • ----

/

/

, • —

;- r / '

y I / t

/ 1 ✓ t

1* I

/►

........ . . 1.............................. •

oT\

3)r \m2.

//

/

7

t I

/ 1

---------

5 4'°-

jo-

/•

/1/

//il rr r H 1 :r j

• -

.

\\\\\•N

N\

\10-

/o.

iIiiI«

//

, . . .

N\ •k\\\\

Q -----1-----1-----1-----r i i i * »& /Z /Q Z* 3 0 f * 4^ Sf 6

K oiv/'T'HS Sl^C-ir

,0 M> 73. 78 8* 9o <?£> /Ol ioQ Uf /a

Oa/S£<T o f E m P Y E m R

o fit> '3$

116Graph No. 2 shows s u r v i v a l s and d e a t h s i n f o r t y - s i x o f t h e

f i f t y empyema c a s e s w hich o c c u r r e d i n p a t i e n t s w i t h u n i -

1 a t e r a l p n e u m o th o p a c es .

Of th e t w e n t y - f i v e d e a t h s , 1+8# had o c c u r r e d w i t h i n two y e a r s

o f o n s e t o f empyema,80# w i t h i n 5 y e a r s and 90# i n a l i t t l e

o v e r 6-J- y e a r s .

Of t h e t w e n t y - o n e c a s e s o f s u r v i v a l , 100# have l i v e d 3 f

y e a r s , 5 0 # have s u r v i v e d 6^ y e a r s and 15# have s u r v i v e d lO y ea r s .

G r a p h kTo . 2 , . - / c M P r e M f i r f l iiv/--------------- 2 . 5 C n s a s W H I C H H fW G DIET)

Z i C f j s e s w hich Hfwe S oR ,i/n /eo

qo-

Qo-

tS

\ \%•\\\\\\

* — -ss

• ------ •//

/ L _ ... W!.

sm'

_ r - * \// \

z .■A

1/s

J»1

' * / 1J I

\

s ' “ ■

ii/

\I/ 1• —•\

a. * \

/•\ \ \

/ \/ \

?i \' \

!i

\\\\

i

10-

r•1

liIi

•I , .

!

\\ t

\%

%V st

O ■ 1 1 1 1 l----r i i i i i4 /2 16 2* 3o 34 +2 5? 4O ^ 72 7G 8? 9

• • i - V I I 1* toX foB lllf. fXo !X(a 11% HB)

f tOf i / ' fHS f f t C M o r J s e r O P E / M P y g / n f l

117

Graph. No, 3 shows t h e d u r a t i o n o f s u r v i v a l o f s i x t e e n

p a t i e n t s who have d i e d and o f s ev en p a t i e n t s who a r e

a l i v e a f t e r u n i l a t e r a l empyema i n " b i l a t e r a l pneum othorax .

The o n ly s u r v i v i n g c a s e o f " b i l a t e r a l empyema

i s n o t i n c l u d e d .

I t c a n he s e e n t h a t w hereas i n t h e c a s e s o f

u n i l a t e r a l p n eum othorax and empyema,72 % o f t h e d e a t h s

had o c c u r r e d w i t h i n t h r e e y e a r s , a l i t t l e u n d e r 50 % o f

t h e c a s e s i n which c o n t r o l o f t h e c o n t r a l a t e r a l s i d e

had "been o b t a i n e d by pneum othorax ,h a d d i e d a f t e r an

i n t e r v a l o f t h r e e y e a r s f rom o n s e t o f empyema.

The g ra p h o f s u r v i v a l s shows t h a t 100 % o f

t h e b i l a t e r a l pneum othorax c a s e s s u r v i v e d f o u r y e a r s ,

and 85 % s u r v i v e d f o u r and a h a l f y e a r s .

The u n i l a t e r a l pneum othorax c a s e s , on t h e

o t h e r hand , show s ' s u r v i v a l f o r f o u r and a h a l f y e a r s

o f 78 % .

So f a r , 50 % o f t h e b i l a t e r a l A. P. c a s e s

have s u r v i v e d more t h a n s e v e n y e a r s , and 50 % o f t h e

u n i l a t e r a l A.P. c a s e s have s u r v i v e d s i x and a h a l f t o

s e v e n y e a r s .

G r a p h N o 3 .

Uni lateral Fmpvh m /vta /m 3 / l a t e r a l A.Ps/4> Co-ses 7 Co.sc.s

iJkicU Lo vie vdkicK ko.vid.

AiecLSuRs/i\/e.<i-

yo .

d« -

\II11«111« - — /----• /\ /1 / v

//

//

/

; n

"0m70O^ 7 0 -

Obo-

•— —»-////•///t

A — * »l1\1vt

- d3a^ S O -inZ

S' ^ . /

;I/1(

9////8 .. —•

»i1\1\

3o-

/9

/J

*m— ~ 9s

tI

II . ___ __

111111111ts

/o -

1II1II1/I/;

II1•

> 6 /1 / 6 ^ 30 42 48 s f bo (J» 7 x 78 04 fo 46 /ot /«6 "f '10 /j6 /jz As6

Months since o n s £ t of Fmpvema

118PI e u r o - C u ta n e o u s S i n u s e s

T r e a tm e n t o f t h e e i g h t y - o n e empyemata r e s u l t e d i n

tw e n ty - tw o c a s e s ( 2 7 . 1 / 3 d e v e l o p i n g p l e u r o - c u t a n e o u s

s i n u s e s . One o t h e r p a t i e n t d e v e lo p e d t u b e r c u l o u s

n o d u l e s i n t h e s k i n f o l l o w i n g a s p i r a t i o n and Azo T.

l a v a g e .

S i n u s e s r e s u l t e d i n t h e d i f f e r e n t fo rms o f

t r e a t m e n t as shown i n T a b le 68.

TABLE 68

P 1e u r o - Cutaneons S in u s e s . 22 Cases

T r e a t m e n t . T o t a l.T rea ted

C ases o f S i n u s

A l i v e Dead L o s t S i g h t o f .

Eo. / - )

A s p i r a t i o no n ly

23 3 1 3 . 0 0 3 0

A s p i t n . and Lavage w i t h Azo T. and combined s o l t n s 23 3 1 3 .0 2 1 0

A s p t n , l a v a g e and S u lp h o n - amide powder and p e n i c i 11i n i r. t r a -; 1 e u r a 1 l y 6 2 33 .3 0 2 0

A s p i r t n . e t c . t h e n c l o s e d d r a i n a g e nO 8 100. 0 2 6 0

CP e o t h o r a x 9 6 66 .6 b r 2 0

T o t a l 69 22 8 I k 0

119Only 69 p a t i e n t s a r e shown i n t h e T a b l e .

The r e m a i n i n g n in e o a s e s were t r e a t e d by t h o r a c o p l a s t y

F o u r t e e n ( 6 3 .7 / 0 o f t h e tw e n ty - tw o p a t i e n t s a r e

dead and e i g h t ( 3 6 . 3 %) a r e a l i v e . The l o n g e s t

p o s s i b l e s u r v i v a l was 1° y e a r s and 9 months and t h e

s h o r t e s t 3 y e a r s f rom f i r s t a p p e a r a n c e o f s i n u s e s .

A p p a r e n t l y (as would be e x p e c t e d ) t h e

t r e a t m e n t most l i k e l y t o l e a d t o s i n u s f o r m a t i o n

i s t u b e d r a i n a g e .

O l e o t h o r a x i s t h e second w o r s t ty p e o f

t r e a t m e n t w h i l e th e t r e a t m e n t l e a d i n g t o th e

f e w e s t c a s e s o f s i n u s e s was a s p i r a t i o n e i t h e r a l o n e

or w i t h l a v a g e .

Of th e s i x o l e o t h o r a x c a s e s , f i v e had o l e o

t h o r a x a s t h e i r f i n a l t r e a t m e n t . One case i s s t i l l

h a v in g a s p i r a t i o n s , w h i l e t h e s i x t h case was f i n a l l y

t r e a t e d by t h o r a c o p l a s t y .

Of t h e two c a s e s a l i v e w h ic h had t o o 1T.

l a v a g e and a s p i r a t i o n , one i s v e r y i l l ; t h e o t h e r

u l t i m a t e l y had a t h o r a c o p l a s t y , and i s w e l l and working

A s i m i l a r p o s i t i o n o b t a i n s as r e g a r d s two p a t i e n t s

a l i v e a f t e r tu b e d r a i n a g e t r e a t m e n t .

T h i r t e e n (59$) o f th e tw e n ty / - tw o c a s e s w i t h

s i n u s e s had had b r o n c h o - p l e u r a l f i s t u l a e .

120

D u r a t i o n o f T r e a tm e n t b e f o r e S in u s e s d e v e l o p e d .

S ix c a s e s (2 7 .3 $ ) d e v e lo p e d s i n u s e s be tw een

t h r e e and. s i x months and e i g h t c a s e s (3 6 . 4 $ be tw een

s i x and n in e months from t h e s t a r t o f t r e a t m e n t o f

t h e i r em p y em ata . I n t h e o t h e r e i g h t c a s e s t h e d a t e

o f d e v e lo p m e n t o f s i n u s e s i s no t known. One case,

had t o have a s p i r a t i o n s s to p p e d a f t e r 4-§- months

b e c a u s e o f t h e d ev e lopm en t o f m u l t i p l e s i n u s e s . Two

c a s e s were t u r n e d down f o r t h o r a c o p l a s t y b e c a u s e o f

t h e s t a t e o f t h e i r c h e s t w a l l s .

T r e a t m e n t o f S i n u s e s

V a r io u s co m b in a t io n s o f cod l i v e r o i l and

su lp h o n a m id e powder i n p a s t e , p romin j e l l y , cod

l i v e r o i l a l o n e and p e n i c i l l i n powder a lo n e were

u se d i n a t t e m p t s t o c l o s e s i n u s e s . None were s u c c e s s

f u l . The o n ly s a t i s f a c t o r y t r e a t m e n t was e x c i s i o n

a t t h o r a c o p l a s t y . One p a t i e n t o n ly had t u b e r c l e

b a c i l l i i s o l a t e d from t h e s i n u s . T rea tm en t was

by cod l i v e r o i l d r e s s i n g s and was u n s u c c e s s f u l .

The s i n u s was e x c i s e d a t t h o r a c o p l a s t y .

121S t a t e o f Sputum i n P a t i e n t s d i s c h a r g e d from S a n a t o r i u m .

Of t h e t o t a l number o f s e v e n t y - e i g h t

empyema c a s e s , f o r t y - t h r e e ( 5 5 .1 $ ) a r e dead and

t w e n t y - n i n e ( 3 7 .2 $ ) a r e a l i v e . S ix p a t i e n t s ( 7 .7 $ )

were l o s t s i g h t o f . Of t h e f o r t y - t h r e e p a t i e n t s

who d i e d , s i x t e e n (3 7 .2 $ ) d i e d i n h o s p i t a l . Twenty-

s e v e n ( 6 2 .8 $ ) d i e d a t v a r y i n g i n t e r v a l s a f t e r d i s

c h a r g e .

The s t a t e o f sputum c o n v e r s i o n a t d i s c h a r g e

o f t h e t w e n t y - s e v e n p a t i e n t s who have d i e d s i n c e d i s

c h a r g e and o f t h e t w e n t y - n i n e s t i l l a l i v e i s shown

i n T a b le 69•

TABL

E 69

. 56

oa

ses

disc

harg

ed

from

Ho

spit

al

-FU~crf<Dft

<D>•HrH

n3crf©ft

©>•HrH<rf

'd © crH «HCrf ft -P B O OEh O

OP

I rHf t O erf O p P

I HO erf E-) -P

crfP I© O [xj •P £ erf oorf 3

©H £3 n p -p

©c ftP P + 3

I rHf t O crf

gr O p P

U ft O

Ios*:*£ erf O Ph ft O

I rHO erf

|Eh -P

Io £ p © -

.. a ftPQ P +J

X •erf OP ft O

x;erf PM © o P P ftP P -P

. P ©P erf hDO P£ erf © P Pi p p o erf P TO p p , *H CO ca p

122'5f1oCO

wCO

"sH

02

r> o- 02H 02 H

LO CO

CD!> CO

CO ^

(Q O LO rH

LO H 1 CO

CO LO (X?

LO

CO03

P - CO• •

CD COCD LQ

00

02

03 H LO

©>P•rlmOft

©>•HPerfW©ft

£P

pPft©oft

ooo

CDLO

ft03

03rH

LOrH

0103

CO

H03

rHCrfPOP-

ro©beaS’

•H

1rHrHO<w

2P

P•H

poftm©ft

rH•H£rapP©•HPcrfftPOmftpOPbOftPOftPOrH

%•H>PPCO

123

Sputum on D i s c h a r g e .

TA3L3 7 0 . 27 P a t ie n t s who haved ied s in c e d i s c h a r g e .

Sputum a t D isch a rg e

U n i la t e r a l A .P . Cases

B i l a t e r a l A .P . Cases

TotaI ^

P o s i t i v eSputum 8 5 13 4 8 .2

N egativeSputum 5 4 9 33 .3

No Sputum 2 3 5 18 .5

T o t a l 15 12 27 100.0

Of th e t h i r t e e n p a t ie n t s d isch a rg ed w i th

a p o s i t i v e sputum th e s u r v iv a l was as fo l lo w s :

■Srythocyte se d im e n ta t io n r a te on d isc h a r g e i s a l s o

g iv en j- See Table 71 on page 124.

124

P a t i e n t s d isc h a r g e d w i t h P o s i t i v e Sputum who have

s in c e d i e d .

TABLE 71 . 13 P a t ie n t s •

Case U n i l a t e r a l E .S .R . Case B i l a t e r a l E .S .R .Ho. Pneumo- a t No. Pne umo- a t

t h o r a c e s . d i s t h o r a c e s . d i s S u r v iv a l charge . S u r v iv a l chargea f t e r d i s m.m. a f t e r d i s m.m.charge • 2 hr s . charge . 2 hr s •

Years (W.) Years . (w .)

1 1 4 /1 2 123 1 3 1/12 622 1 7 /1 2 71 2 4 483 2 2 /1 2 52 3 4 424 2 6 /12 23 4 4 345 3 39 5 4 6 /12 516 4 167 54 128 Wot known 14

The above Table seems t o show th a t in

g e n e r a l terms p a t ie n t s w ith a p o s i t i v e sputum on d i s

charge s u r v iv e d a lon ger or sh o r te r t im e , a c c o r d

in g t o th e r a p i d i t y o f the s e d im e n ta t io n r a t e a t

d i s c h a r g e .

125P a t i e n t s d isc h a r g e d w i th N egative Sputum who have

d i e d .

TAB LSI 7 2 . 9 P a t ie n t s

CaseNo.

U n i l a t e r a l A .P .

S u r v iv a l a f t e r d i s charge .

Years

E .S .R .a tD i s chargem.m.2 h r s . ( W . )

CaseNo.

3 i l a t e r a l A .P .

S u r v iv a l a f t e r d i s charge .

Years

E .S .R .a tD i s chargem.m.2 hrs •

( w .)

1 2 7 /1 2 41 1 1 7 /12 712 3 30 2 4 6/12 275 3 6 /12 23 3 6 284 5 6 /12 66 4 7 6 /12 205 10 46

I t would appear t h a t w h ile s u r v iv a l a f t e r d i s

charge w i th n e g a t iv e sputum appears t o he r e l a t e d

t o th e r a p i d i t y o f the se d im e n ta t io n r a te a t the

tim e o f d i s c h a r g e , th ere i s not the same c o r r e l a t i o n

betw een ra p id se d im e n ta t io n r a t e and sh o r te r s u r v iv a l

as i s found w i t h c a se s which had p o s i t i v e sputum on

d i s c h a r g e . This i s as would be e x p e c te d , namely,

t h a t th e im portant f a c to r i n le n g th o f s u r v iv a l i s

th e s t a t e o f the sputum, not the r a p i d i t y o f the

s e d im e n ta t io n r a t e .

12 6P a t i e n t s d isc h a r g e d w ith No Sputum who have d i e d .

TABLii 7 5 . 5 Cases

CaseN o ,

U n i l a t e r a l A . P ,

S u r v iv a l a f t e r d i s charge

Years

E .S .R .a td i s charge m.m •2 hrs . (W.)

CaseNo.

Si l a t e r a l A .P .

S u r v iv a l a f t e r d i s c h a r g e .

Years

E .S .R .a td i s chargem.m.2 hrs . (W.)

1 7 40 1 2 6/12 402 8 2 /1 2 10 2 X 4 43

3 7 30

X Case o f b i l a t e r a l empyema .

No c o n c lu s io n s can be drawn from the f ig u r e s

in Table 73 .

P a t ie n t s d isch a rg ed from Sanatorium who are known

t o be a l i v e .

Tw enty-nine p a t ie n t s ( 3 7 ,2%) o f th e t o t a l

number o f s e v e n t y - e ig h t c a se s o f empyema are a l i v e .

S u r v iv a l ranges from 3-J- t o 10 years from d ate o f d i s

charge from h o s p i t a l .

Of th e s e tw en ty -n in e p a t i e n t s , th e s t a t e

o f soutum a t d isch a rg e i s shown in Table 7 4 .

127

TABLI 74

29 P a t i e n t s now A l i v e

Sputum a t d i s c h a r g e

Uni l a t e r a lPneumothor-a c e s

B i l a t e r a 1 Pne umot ho r - a c e s

T o t a l %

P o s i t i v e 2 2 4 13 .8N e g a t iv e 14 , 4 18 62 .1No Sputum 5 2 7 2 4 . 1

T o t a l 21 8 29 1 00 .0

The f o l l o w i n g T a b le s show t h e s u r v i v a l so f a r

o f t h e s e p a t i e n t s . S e d i m e n t a t i o n r a t e a t d i s

c h a r g e i s a l s o g i v e n .

TABLE 75

4 P a t i e n t s now a l i v e . d i s c h a r g e d w i t h P o s i t i v e Sputum.

Case Uni l a t e r a l E .S .R . Case B i l a t e r a l S .S .R.No. Pneumo- a t No. Pneumo- a t

t h o r a c e s . d i s - t h o r a c e s . d i s S u r v i v a l ch a rg e S u r v i v a l ch a rg ea f t e r m.m. a f t e r m.m.d i s c h a r g e 2 h r s d i s c h a r g e . 2 h r s .

Y ea rs ( W .) Years ( W )

1 4 65 m.m. 1 X 6 952 8 6 m.m. 2 7* = 42

X T h i s case was a b i l a t e r a l empyema, who i s

s t i l l h av in g a s p i r a t i o n s on t h e r i g h t s i d e . He was

t r e a t e d by o l e o t h o r a x on b o t h s i d e s .

T h e re a r e on ly fo u r c a s e s i n t h i s c a t e g o r y .

T h i r t e e n o t h e r s d i s c h a r g e d w i t h p o s i t i v e sputum have

d i e d •

128

TABLE 76

18 P a t i e n t s now a l i v e , d i s c h a r g e d w i t h N e g a t iv e Sputum.

Case U n i l a t e r a l Case B i l a t e r a 1No. Pneumothora ces . No. Pneumothora.ces .

S u r v i v a l E .S .R . S u r v i v a 1 E . S .R .a f t e r d i s a t a f t e r d i s a tc h a rg e d i s c h a r g e c h a rg e . d i s c h a r g e

Y ears m.m.2 h r s .

(W.)

Y ea rs . m.m.2 h r s .

(W.)

1 3 h 23 1 4 502 3$ 17 2 4* 273 4 17 3 6 284 4 19 4 7* 205 4 316 4J 187 358 5 229 3910 7 ? 2711 8f 312 8* 513 9 i 3114 10* 41 |_ . _ _ ___ !

There i s no a p p a r e n t c o r r e l a t i o n b e tw een

l e n g t h o f s u r v i v a l an a s e d i m e n t a t i o n r a t e a t d i s

c h a rg e • The i m p o r t a n t m a t t e r i s t h e f a c t t h a t t h e

spu tum was n e g a t i v e a t d i s c h a r g e .

129

TABLE 77

7 P a t i e n t s now A l i v e , d i s c h a r g e d w i t h No Sputum.

Case U n i l a t e r a l Case B i l a t e r a lWo. Dne umot hors ■X • No. Pne umothor ax

S u r v i v a l E .S .R . S u r v i v a l E . S .R .a f t e r a t d i s a f t e r a t d i s d i s c h a r g e • ch a rg e d i s e h a r g e ch a rg e

Y ears m .m.2 h r s •( w . )

Y ears m.m.2 h r s .(w.)

1 5 27 1 5 502 5 2 /1 2 10 2 6* 323 7 164 8 405 q l y s 34

There i s no c o r r e l a t i o n b e tw een l e n g t h o f

s u r v i v a l and s e d i m e n t a t i o n r a t e a t d i s c h a r g e , b u t

a l l t h e s e p a t i e n t s a r e a l i v e , w e l l and w o r k in g .

130

M a in te n a n c e o f C o l la p s e a f t e r O nset o f Empyema

A f t e r o n s e t o f empyema c o l l a p s e was m a in

t a i n e d i n t w e n t y - f i v e {52%) and abandoned i n f i f t y -

t h r e e (6 8 %) o f t h e t o t a l number o f s e v e n t y - e i g h t

p a t i e n t s •

W i th a f o l l o w - u p w h i c h , a t t h e l o n g e s t from

o n s e t o f empyema was 11-J- y e a r s , and a t t h e s h o r t e s t

3 i y e a r s , t h e p o s i t i o n r e g a r d i n g t h o s e a l i v e and

d e a d i s shown i n T a b le 78 b e lo w .

TABLE] 78

Al ive Dead Lost s i g h t o f

T o t a l

C o l l a p s e m a in t a i n e d 12 11 2 25

C o l l a p s e a b a n doned 17 32 4 53

T o t a l 29 43 6 78

Of t h e t w e n t y - f i v e p a t i e n t s i n whom c o l l a p s e

was m a i n t a i n e d , tw e lv e (48$) a r e a l i v e . I n f i v e

o f t h e s e t h e c o l l a p s e -was m a i n t a i n e d by o l e o t h o r a x .

E l e v e n p a t i e n t s (44$) i n whom c o l l a p s e was m a i n t a i n e d

a r e d e a d , and two have been l o s t s i g h t o f .

Of t h e f i f t y - t h r e e p a t i e n t s i n whom c o l l a p s e

131by pn eu m o th o ra x was a b an d o n ed , s e v e n t e e n (.32$)

a r e a l i v e , t h i r t y - t w o (6 0 .4 $ ) a r e d e a d , and f o u r

( 7 . 6 $ ) a r e l o s t s i g h t o f .

Of t h e s e v e n t e e n p a t i e n t s now a l i v e , t e n

(59$) had no f u r t h e r t r e a t m e n t ( a p a r t f rom a s p i r a t i o n ,

e t c . ) w h i l e s ev en (41$) had t h o r a c o p l a s t y .

Of t h e t h i r t y - t w o d e a d , tw e n ty - o n e had no

f u r t h e r t r e a t m e n t o t h e r t h a n a s p i r a t i o n , w h i l e one

had t h o r a c o p l a s t y .

Of t h e fo u r c a s e s l o s t s i g h t o f , one had

t h o r a c o p l a s t y , b u t t h e o t h e r t h r e e had no f u r t h e r

c o l l a p s e t r e a t m e n t .

A f t e r abandonment o f pneu m o th o ra x , s e v e n t e e n

p a t i e n t s ( a p a r t from one p a t i e n t i n whom t h o r a c o p l a s t y

was p e r fo r m e d ) had a lung w h ich r em a in e d more or

l e s s u n ex p a n d e d . Of t h e s e s e v e n t e e n , t h i r t e e n

( 7 6 .4 $ ) a r e d e a d , two a r e a l i v e ( 1 1 . 8 ) , and two a r e

l o s t s i g h t o f .

Regarding th e c a s e s in which c o l la p s e was

m a in ta in e d , i t i s rea so n a b le to p o in t out t h a t the

trea tm en t o f empyema in th e se c a s e s must have been

s a t i s f a c t o r y .

132

DISCUSSION

DEFINITION AND INCIDENCE OF TUBERCULOUS EMPYEMA

D e f i n i t i o n -

De C ecio and P o t t e r (1939) and Goorwitch (1943)

have commented on th e v a ry in g o p in io n s e x p r e sse d in th e

l i t e r a t u r e as to which type o f e f f u s i o n c o n s t i t u t e s an

empyema d u rin g th e course o f a r t i f i c i a l pneumothorax

tr e a tm e n t .

1 have used the d e f i n i t i o n su g g e s te d hy

D ick ey (1943^ which d e f in e s tu b e r c u lo u s empyema as

a t u r b id or p u ru len t exudate in which t u b e r c le b a c i l l i

have b een dem onstrated , e i t h e r on d i r e c t smear or on

c u l t u r e , or by animal in o c u la t io n . O m s te in and

Ulmar (1939) c o n s id e r th a t a l l tu b e r c u lo u s e f f u s i o n s

sh o u ld be termed empyemata. Munro-Ashman and Tate

(1 9 4 3 ) , r e q u ir e th a t th e e f f u s i o n s h o u ld ,a t l e a s t ,

be tu r b id and th a t tu b e r c le b a c i l l i be dem onstrable

on d i r e c t smear exam ination . C u t le r (1941) used a

s i m i l a r d e f i n i t i o n , but Jones and A lexander (1 9 3 4 ) ,

Woodruff (1938) and Andersen (1 9 4 9 ) , w h ile i n s i s t i n g

th a t th e exudate be tu r b id or p u ru len t ,d o not i n s i s t

on th e d em on stra tion o f th e tu b e r c le b a c i l l u s i n th e

exu d ate . Woodruff (1 9 3 8 ) , i s s a t i s f i e d th a t an

133

an empyema i s tu b e r c u lo u s i f t u b e r c u lo s i s o f th e

u n d e r ly in g lu n g i s proved , w h i l s t Jones and A lexander

(1934) and Andersen (1949) a ccep t as p r o o f o f th e

tu b e r c u lo u s o r i g i n o f th e exudate th e f in d in g o f

tu b e r c u lo u s g r a n u la t io n t i s s u e in b io p sy specim ens o f

th e pleura*

I n c id e n c e -

A p p ly in g th e d e f i n i t i o n o f D ickey (1943) to

t h i s s e r i e s , th e in c id e n c e o f empyema over a p e r io d

o f e i g h t y e a r s between 1937 and 1945 works out a t

e i g h t y - one , e q u iv a le n t to 5.6% o f th e t o t a l number

o f 1 ,4 4 8 pneumothoraces*

There were s i x t e e n o th e r c a s e s o f tu r b id

or p u r u le n t exudate but in none o f th e s e were

t u b e r c l e b a c i l l i e v e r dem onstrated • I f th e s e c a se s

a re in c lu d e d , th e in c id e n c e o f empyema in t h i s

s e r i e s r i s e s to 6.7% o f th e t o t a l pneumothoraces.

The in c id e n c e in t h i s s e r i e s compares favour

a b ly w ith f i g u r e s quoted in th e l i t e r a t u r e , a lth ou gh

o b v io u s ly th e in c id e n c e o f empyema in any s e r i e s

o f pneumothoraces w i l l vary a c co rd in g to th e

d e f i n i t i o n o f empyema accep ted by th e o b serv er .

134

Fhostad i n Norway, quoted by Andersen (1949) has

e s t im a te d th e in c id e n c e a t 10$ as an average f i g u r e .

A lexander (1937) q uotes f ig u r e s ranging .from

n i l ( U l r i c i , 600 c a s e s ) t o tw enty-one per cen t (Hayes

151 c a s e s ) •

Shipman (1942) a l s o c la im ed t o have no

c a s e s o f empyema during a p eriod o f four y e a r s , w h ile

W o lla s to n (1940) had an in c id e n c e o f on ly 2 $ .

U n v e r r ic h t , quoted by U stved t (1942) i n a

s e r i e s o f 2 ,8 9 3 pneumothoraces had the low in c id e n c e

o f 1 .1 $ , w h i le Morrison (1948) rep o r ted an in c id e n c e

o f 2 4 $ i n f i f t y pneum othoraces.

FUrther examples o f the v a r ia t io n o f in c id e n c e

o f empyema i n pneumothorax are shown in Table 79 •

TABLa 79

In c id e n c e o f Empyema in Pneumothorax

Aut hor No. o f Cases o f Pneumothorax

In c id en ce o f Empyema

$

Leaver and Hardaway (1937) 760 5 .8 $

N ic k la s , Fhanklin and Savod (1937) 375 1 4 .4 #Skavlem e t a l (1940) 898 1 0 .8 %M a t t i l l & Jennings (1940) Not g iv e n 1 4 .5 #

C u tler (1941) 476 1 2 .4 #

135

G e n e r a l ly i t may be s a id , d e s p i t e th e

f i g u r e s quoted in Table 79 , th a t as e x p e r ie n c e

o f pneumothorax in c r e a s e d , the in c id e n c e o f empyema

has te n a e d t o f a l l .

L i l i e n t h a l (1925) su g g e s ts th a t between

10$ and 20$ o f a l l exudates in pneumothorax become

p u r u l e n t .

Paquette (192 6) quotes f ig u r e s o f in c id e n c e

o f 4 1 .8 $ i n 1926, 2 6 .1 $ for the p er io d 1920 t o 1930,

and o n ly 9 .4 $ fo r the p er iod 1930 t o 1944.

R ogstad ,q uoted by AndersO® (1949), had an

in c id e n c e o f 6 .4 $ o f empyema in 918 p a t i e n t s , w h ile

o th e r f ig u r e s a lr e a d y quoted above show an in c id e n c e

from 1940 onwards o f 2 $ and n i l .

136

BT10 LOGY

Type and A c t iv i t y o f D isease a t Induction o f Pneumothorax.

Of t h e t o t a l number o f s e v e n t y - e i g h t p a t i e n t s

i n t h i s s e r i e s , s i x t y - t h r e e (a lm os t 81$) were

s u f f e r i n g from e i t h e r a c u t e e x u d a t i v e d i s e a s e o r v

e x t e n s i v e u n i l a t e r a l c a v i t a t i o n , or had a l a r g e

a p i c a l c a v i t y a t t h e t im e o f i n d u c t i o n o f t h e i r pneumo

t h o r a x .

Pour c a s e s were s u f f e r i n g from a c u t e t u b e r

c u l o u s pneumonia when pneumothorax was i n d u c e d ,

F i f t y - t h r e e c a s e s (69,2%) came i n t o S a l k i n

and C ad d e n Ts (1941; c l a s s i f i c a t i o n o f f a r ad v an ced

d i s e a s e , and s i x t y - e i g h t (87.2%) i n t o th e d i f f e r e n t

c a t e g o r i e s s u g g e s t e d by R a f f e r t y (1944) a s u n s u i t a b l e

f o r t r e a t m e n t by pneum othorax .

S i x t y - o n e p a t i e n t s (78%) had symptoms o f

tw e l v e months or l e s s d u r a t i o n ( co u n ted from t h e

t im e o f t h e f i r s t ap p e a ra n ce o f symptoms b e f o r e a

d o c t o r was c o n s u l t e d ) and f i v e c a s e s ( 6 .4 $ ) only^

had bed r e s t a f t e r a d m i s s i o n t o t h e Sanator ium, and

p r i o r t o i n d u c t i o n o f pneumothorax o f more t h a n 2

v/eeks d u r a t i o n .

137.Table 19 shows th a t s i x t y - n i n e (8 5 .2 $ ) o f

th e e i g h t y —one empyemata had th e pneumothorax induced

when th e e r y th r o c y te sed im en ta tio n r a te was 40 m.m.

o r more in two hours (W estergren ).

In t h ir t y - o n e in s t a n c e s (38$) , th e e . s . r

was e i t h e r 80 m.m. or more (W estergren) when pneum

o th o ra x was induced. I t has been, our e x p e r ie n c e in

th e C h esh ire J o in t Sanatorium in r e c e n t y e a r s , th a t

pneum othoraces induced when the e . s . r. i s 40 m. m. or

o v er in 2 hours(W .) have shown a p r o p o r t io n a te ly h ig h er

in c id e n c e o f e f f u s i o n than th o se induced when the

s e d im e n ta t io n r a te was below 40 m. m. in 2 hours (W. ) .

A l l th e above f in d in g s confirm the e x p e r ie n c e

o f most o th e r o b se r v e r s .

Packhard, Hayes and B lan ch et (1 9 4 0 ) , s t a t e

t h a t th e more a c t i v e th e pulmonary l e s i o n a t th e time

o f in d u c t io n o f pneumothorax , th e more freq u en t and

more s e r io u s th e p le u r is y . P inner ( 1 9 4 4 ) , rep orted

th a t a c u te and caseous involvem ent i s f r e q u e n t ly

c o n s id e r e d an a b so lu te c o n t r a - in d ic a t io n to pneumo

th o ra x on account o f th e r e a l danger o f empyema.

Table 18 shows th a t 28 p a t ie n t s in t h i s s e r i e s

eq u a l to a lm ost 36$ o f th e t o t a l number had t h e i r

pneumothoraces induced when s u f f e r in g from acu te

c a seo u s d ise a se * Hayes(1 9 2 7 ) , Skavlem and o t h e r s (1 9 4 0 ) ,

and R a ffe r t{r19/ 4) a l l agree th a t c o l la p s e o f a lung by

138

pneumothorax w h i le th e d i s e a s e i s a cu te runs th e r i s k

o f prod u cin g c o m p lic a t in g e f f u s i o n and empyema.

W o lla s to n and Landau (1 9 4 6 ) , on the o th e r hand,

d i s c u s s i n g s e d im e n ta t io n r a te a t th e tim e o f in d u c t

io n o f pneumothorax and a c c e p t in g the se d im e n ta t io n

r a t e as one in d ic a t o r o f a c t i v i t y , c o n s id e r th a t a

r a p id s e d im e n ta t io n r a te i s i t s e l f n ot a c o n tra

i n d i c a t i o n to in d u c in g pneumothorax. These w r i t e r s

a re o f th e o p in io n th a t e f f e c t i v e c o l la p s e ,and n o t

th e i n i t i a l se d im e n ta tio n r a t e , i s th e s i g n i f i c a n t

f a c t o r in a v o id in g c o m p lic a t io n s .

W h ils t a c c e p t in g th e l a t t e r s ta tem en t th a t

c o l l a p s e i s v ery im portant in so fa r as a s a t i s f a c t o r y

c o l l a p s e i s more l i k e l y to c o n tr o l th e d isease? and th a t

t h e r e i s a c o r r e sp o n d in g ly sm a lle r r i s k o f c o m p lic a t in g

e f f u s i o n and empyema, our e x p e r ie n c e has b e e n ,a s

shown in T ab les 19 and 20 th a t a h igh sed im en ta tio n

r a t e a t in d u c t io n c o in c id e s w ith c o m p lic a t io n s . T h is

i s s t i l l our e x p e r ie n c e and we are now f in d in g few er

c a s e s d e v e lo p in g co m p lic a t in g e f f u s i o n s and empyemata

by u s in g th e e. s . r. to in d ic a te when a c a se needs

t im e ,o r o th e r measures^such as p h ren ic crush and

pneumoperitoneum, to a l lo w i t to ne o o l o f f ” b e fo r e

uneumothorax i s induced.

139

Type o f C o l la p s e

T a b le 29 3hows t h a t o f s e v e n t y - f o u r c a s e s

o f p n eu m o th o ra x s u b m i t t e d t o a d h e s i o n s e c t i o n ,

t w e n t y - s i x c a s e s ( 3 5 .1 $ ) had s a t i s f a c t o r y c o l l a p s e ,

and f o r t y - e i g h t ( 6 4 .9 $ ) had e i t h e r i n c o m p le te

o r i n e f f e c t i v e c o l l a p s e a f t e r o p e r a t i o n . Seven c a s e s

n o t s u b m i t t e d t o a d h e s i o n s e c t i o n a l l had i n e f f e c t i v e

c o l l a p s e . T h u s , o f t h e t o t a l number o f e i g h t y - o n e

em pyem ata , f i f t y - n i n e (6 7 .9 $ ) d e v e lo p e d i n pneumo

t h o r a c e s e i t h e r i n c o m p l e t e l y or i n e f f e c t i v e l y c o l l a p s e d .

Edwards & Lynn (1 9 3 9 ) , Browning, Dundon.

and Ray ( 1 9 4 1 ) , C u t l e r ( 1 9 4 1 ) , Dickey (1 9 4 3 ) ,

S h i e l d s (1944) and W o l l a s to n and lan d au (1946) a l l

a g r e e t h a t e f f u s i o n and empyema a r e more prone t o

o c c u r i n pneum othora ces m e c h a n i c a l l y i n e f f e c t i v e and

m a i n t a i n e d a s s u c h f o r t o o long a p e r i o d .

I t would seem, a l s o , t h a t complete or

s a t i s f a c t o r y c o l l a p s e i s th e l e s s common o c c u r r e n c e .

Edwards & Lynn (1939) found complete d i v i s i o n o f

a d h e s i o n s p o s s i b l e i n e i g h t y - s i x (34$) o f two

h u n d r e d and f i f t y - f i v e c a se s s u b m i t t e d t o o p e r a t i o n .

P a r t i a l c o l l a p s e was o b t a in e d i n one hundred and

f o r t y c a s e s (55$) and tw e n ty - n in e case s (11$) were

found t o be i n o p e r a b l e .

140C h an d le r (1937) o b t a i n e d com ple te c o l l a p s e

i n 5 0 $ , A nderson and A lex an d e r (1937) i n 3 7 $ ,

a l t h o u g h Jaco b eu s (1923) i n h i s e a r l y c a s e s c la im e d

t o have o b t a i n e d comple te c o l l a p s e i n 75 $ .

I t may be s u r p r i s i n g t o no te t h a t i n t h i s

s e r i e s t w e n t y - s i x c a s e s (3 5 .1 $ ) o f pneumothorax

d e v e l o p e d empyema d e s p i t e s a t i s f a c t o r y c o l l a p s e .

M a tso n , Matson & B i s a i l l o n ( 1 9 2 4 ) , however , found

t h a t t w e n t y - n i n e (49.2%) o f f i f t y - n i n e empyemata

i n t h e i r s e r i e s d e v e lo p e d i n c a s e s o f s a t i s f a c t o r y

c o l l a p s e .

P a c k h a r d , Hayes & B la n c h e t (1940) s u g g e s t

t h a t i n s u c h c a s e s " seepage o f t u b e r c l e b a c i l l i

may o c c u r from a s u b - p l e u r a l focus i n t o t h e p l e u r a l

c a v i t y a f t e r t h e p l e u r a has been r e n d e r e d v e r y a l l e r g i c

b y t h e p r e v i o u s m i ld i n f e c t i o n s . "

The same o b s e r v e r s no te t h a t a s e ro u s e f f u s i o n

may become p u r u l e n t d u r in g a c o ld or an y s e p t i c

i n f e c t i o n .

I n t h i s s e r i e s t h e causes[of empyema i n t h e

t w e n t y - s i x c a s e s i n whom s a t i s f a c t o r y c o l l a p s e

was o b t a i n e d w e r e , so f a r a s cou ld be a s c e r t a i n e d ,

a s f o l l o w s : -

141.

1. In e ig h te e n {,69.2%) d e s p i t e s a t i s f a c t o r y

c o l l a p s e , d i s e a s e was n o t c o n t r o l l e d through f a i l u r e

t o a c h ie v e c a v i t y c lo s u r e . In e ig h t o f t h e s e c a s e s

b r o n c h o -p le u r a l f i s t u l a develop ed .

2. Three c a s e s had haemothorax d e v e lo p

f o l l o w i n g a d h es io n s e c t io n .

3. Three c a s e s d eve lop ed com plete a t e l e c t a s i s

a f t e r a d h e s io n s e c t i o n . S in ce r o u t in e bronchoscopy

h a s b een p r a c t i s e d in th e Sanatorium i t has been found

t h a t such c a s e s have always p r e se n t en d o -b r o n c h ia l

d i s e a s e o f one or more major b ro n ch i. There i s no

r e a so n t o doubt th a t s im i la r f in d in g s would have

b een r e p o r te d in th e th r e e c a s e s m entioned above.

4. In one ca se in which c a v i t y c lo s u r e

was o b ta in e d , b r o n c h o -p le u r a l f i s t u l a d eve lop ed

through a markedly tu b e rcu lo u s p leu ra .

5. In one ca se th e e x a c t cause o f empyema

(w hich was l a t e In d ev e lo p in g ) was n o t a s c e r ta in e d .

142 .A t e l e c t a s i s .

Complete a t e l e c t a s i s o f t h e lung o c c u r r e d

i n t w e l v e c a s e s , e q u a l t o 1 4 .8 $ o f t h e t o t a l number

o f e i g h t y - o n e empyemata and 1 6 .2 $ o f t h e s e v e n t y - f o u r

c a s e s o p e r a t e d upon f o r a d h e s i o n s . By a t e l e c t a s i s

i s meant t h e f i n d i n g on t h e s k ia g ra m o f a g round

g l a s s a p p e a r a n c e o f a lobe o r o f a whole lung accom

p a n i e d by c l i n i c a l s ig n s s u c h as m a l l a i s e and p y r e x i a

o f v a r y i n g d e g r e e .

Only com ple te a t e l e c t a s i s o f th e whole lung

i s b e i n g c o n s i d e r e d i n t h e c a s e s o f empyema under

r e v i e w , f o r t h e r e a s o n t h a t , i n g e n e r a l , our e x p e r i e n c e

h as b e e n t h a t l o c a l i s e d l o b a r or s e g m e n ta l a t e l e c t a s i s

has more u s u a l l y r e s u l t e d i n h e a l i n g and f i b r o s i s

o f t h e a f f e c t e d a r e a , w i t h no m ass ive e f f u s i o n or

empyema a s a r e s u l t . Complete a t e l e c t a s i s o f an

e n t i r e l u n g , on t h e o t h e r hand , has been fo l lo w e d

by m a ss iv e e f f u s i o n and empyema. T h i s has been

o b s e r v e d a l s o by C u th b e r t and Nag l e y (1 9 4 8 ) .

I t would a p p e a r t h a t empyema may fo l lo w

a t e l e c t a s i s a s t h e r e s u l t o f -

1 . E x t e n s i o n o f p e r i p h e r a l b r o n c h i a l d i s e a s e

t o c a s e a t i o n and e r o s i o n o f th e v i s c e r a l p l e u r a

w i t h f o r m a t i o n o f b r o n c h o - p l e u r a l f i s t u l a .

143

F iv e o f th e tw e lv e c a s e s o f a t e l e c t a s i s in

t h i s s e r i e s d e v e lo p e d dem onstrable b r o n c h o -p le u r a l

f i s t u l a e .In th e p rese n c e o f major en d o -b ro n ch ia l

t u b e r c u l o s i s , m a ss iv e c o l la p s e o f th e lung may occur

w ith con seq u en t spread o f parenchymatous d i s e a s e to

th e p le u r a .

In r e c e n t y e a r s , s in c e r o u t in e bronchoscopy^

h a s b een p r a c t i s e d in th e C heshire J o in t Sanatorium,

th e above f in d in g s have been confirm ed in every c a se .

Rapid r e - a e r a t io n o f th e lung has n o t p revented the

o c c u r r e n c e o f b r o n c h o -p le u r a l f i s t u l a e , ( e v e n a f t e r

an i n t e r v a l o f th r e e months ) in such c a s e s and even

a f t e r a p p a r e n t ly s a t i s f a c t o r y r e s o l u t i o n o f th e

tu b e r c u lo u s b r o n c h i t i s by th e u se o f strep tom ycin .

T h is would seem to confirm th e o b se r v a t io n o f Maher-

Loughnan ( 1 9 5 0 ) , s u g g e s t in g th a t t u b e r c u lo s i s o f the

s m a l le r b ro n ch i and b r o n c h io le s e x i s t s in a l l c a se s

o f a t e l e c t a s i s , and i s , perhaps, the cause o f lob ar

a t e l e c t a s i s o c c u r r in g suddenly in c a s e s o f s a t i s f a c t o r y

c o l l a p s e .

T ab le B3 shows no c o n s is t e n c y o f f in d in g s in

th e c a s e s i n which com plete a t e l e c t a s i s occurred . This

i s n o t s u r p r is in g in th a t any, or in d e e d t every case

o f pulmonary t u b e r c u lo s i s must a t some tim e have a d egree o f

144

tu b e r c u lo u s b r o n c h i t i s . I t d o e s , however, r a i s e th e

q u e s t io n o f why com plete a t e l e c t a s i s o ccu rs in

some c a s e s o f pneumothorax and n o t in o th e r s .

To answer t h i s q u e s t io n in v o lv e s one in

th e com p le te p a th o lo g y and e t i o l o g y o f a t e l e c t a s i s ,

f o r whieh th e r e i s n o t space in t h i s t h e s i s . S u f f i c e

i t to sa y t h a t one or more or a l l the c a s e s which

d e v e lo p e d com plete a t e l e c t a s i s may have had p r e se n t

one or a l l o f th e c o n d it io n s m entioned b elow , which

may induce a t e l e c t a s i s :

1. O b str u c t io n o f a major bronchus. C o r y l lo s

( 1 9 3 3 ) , Kent (1942) , Paulson and Shaw (1 9 4 9 ).

2. K inking and p a r t i a l s t e n o s i s o f a major

bronchus w ith p r o g r e s s io n l a t e r t o ’’ch eck -V a lv e”

o c c l u s i o n in th e p resen ce o f en d o -b r o n c h ia l tu b e rc

u l o s i s . K orol (1936^ , R a f fe r ty (1 9 4 3 ) , Sampson

( 1 9 3 7 ) , B ra n tig a n e t a l . (1942) , Viswanathan (1949).

P a r t i a l s t e n o s i s o f a bronchus has been found in

most c a s e s o f a t e l e c t a s i s subm itted to bronchoscopy

in our Sanatorium in r e c e n t y e a r s . C heck-valve

mechanism i s in s ta n c e d by the f i v e c a s e s shown

in T able 25 as hav ing s u f f e r e d b r o n ch o -p leu ra l f i s t u l a .

P lu g s o f s e c r e t i o n have been mentioned as a cause

o f a t e l e c t a s i s by in d u cin g a ch e c k -v a lv e mechanism

s im i l a r t o th a t induced by en d o-b ron ch ia l t u b e r c u lo s i s .

I t has been our e x p er ien ce th a t such p lu gs o f s e c r e t i o n

are n o t commonly th e cause o f com plete a t e l e c t a s i s .

145

3 , P e r i p h e r a l lung i n f l a m m a t i o n ( p n e u m o n i t i s )

and. t u b e r c u l o s i s o f t h e s m a l l p e r i p h e r a l b r o n c h i .

Sloe©s%3? ( 1 9 3 4 ) , P in n e r ( 1 9 4 4 ) , B a r n w e l l , L i t t i g

and Gulp ( 1 9 3 7 ) . P e r i p h e r a l lung i n f l a m m a t i o n

must have e x i s t e d i n f i v e o f th e tw e lv e c a s e s shown

i n T a b le 23 a s h av in g u n h e a l t h y p l e u r a . T u b e r c u l o s i s

o f t h e s m a l l p e r i p h e r a l b r o n c h i may w e l l have e x i s t e d

i n t h o s e c a s e s i n whom c a v i t y c l o s u r e was n o t ob

t a i n e d and a l s o i n t h o s e c a s e s i n w h ic h b r o n c h o

p l e u r a l f i s t u l a e o c c u r r e d .

4 . A c t iv e c o n t r a c t i o n o f t h e a l v e o l i caused

b y r e f l e x i n c r e a s e o f pulmonary to n e 9 X a l a b a r d e r

( 1 9 4 9 ) .

X a l a b a r d e r (1949) has r e v i v e d t h i s t h e o r y

o f a r e f l e x cause f o r pulmonary or s e g m e n ta l a t e l e c t a s

i s and w h i l e i t may be d i f f i c u l t t o a c c e p t t h a t

c o m p le te c o n t r a c t i o n o f th e lung cou ld f o l lo w from

s u c h s t i m u l i , i t may w e l l be t h a t a d h e s i o n s e c t i o n ,

e s p e c i a l l y where a d h e s i o n s a re e x t e n s i v e , might

p r o v i d e j u s t su ch a s t i m u l u s .

I n f i v e o f th e c a s e s l i s t e d i n T ab le 23

c o m p le te a t e l e c t a s i s fo l lo w e d a t a s h o r t i n t e r v a l

f ro m a d h e s i o n s e c t i o n , and i t i s not e a s y t o d i s s o c i a t e

t h e cau se and e f f e c t i n t h e s e c a s e s .

11+6

Summing up , i t may be s a i d , t h e r e f o r e ,

t h a t i n t h e tw e lv e c a s e s which d e v e lo p e d a t e l e c t a s i s

f o l l o w e d hy empyema t h e developm ent o f h o t h t h e s e

c o m p l i c a t i o n s may have b e e n due t o

1 . t h e p r e s e n c e o f e n d o - b r o n c h i a l t u b e r c u l o s i s

i n m a jo r and m inor b r o n c h i . Such t u b e r c u l o u s b r o n c h i t i s

i s known t o be a c o n t r a - i n d i c a t i o n t o t r e a t m e n t by

p n eu m o th o ra x .

2 . The p r e s e n c e o f u n h e a l t h y p l e u r a .

3 . The e f f e c t s o f a d h e s i o n s e c t i o n .

147

E x te n t o f A d h es io n s*

The e x t e n t o f a d h es io n s c a u t e r iz e d was

n o t record ed in th e n o te s , hut i f i t i s a ccep ted

t h a t th e t im e sp en t on the o p e r a t io n i s d i r e c t l y

r e l a t e d to th e area c a u te r iz e d , i t i s p o s s i b l e to

gauge th e e x t e n t o f the a d h es io n s . On th e o th e r

hand, i t i s p o s s i b l e th a t where e x t e n s iv e a d h es io n s

e x i s t e d o n ly th e most a c c e s s i b l e were d iv id e d , and

a c o r r e sp o n d in g ly sh o r t tim e would be recorded in

th e n o t e s .

T ab les 25 , 26 and 27 show th a t tw en ty -

se v e n (60%), o f f o r t y - f i v e c a s e s op erated upon in

w hich th e a c t u a l c a u t e r iz a t io n tim e i s recorded

had a d h es io n s e c t io n s o f more than t h i r t y m inutes

d u r a t io n . F iv e c a s e s (11.1%) had t o have two

s e s s i o n s each , o f v a ry in g d u ra tio n .

Edwards and Lynn (1939) found th a t

e f f u s i o n and empyema were more common in c a se s

i n w hich , i n t e r a l i a , e x t e n s iv e c a u t e r i z a t io n o f

a d h e s io n s had been performed.

148

S i g n i f i c a n c e o f Adhesions

P o s i t i v e p r e s s u r e s were used i n t w e n t y - f o u r

(29.6%) o f th e e i g h t y - o n e pneum othoraces t o m a i n t a i n

t h e c o l l a p s e a f t e r a d h e s i o n s e c t i o n .

S t o b i e (1950) s u g g e s t s t h a t t h e t e a r i n g

o f a n a d h e s i o n may r e s u l t from t h e use o f p o s i t i v e

i n t r a p l e u r a l p r e s s u r e s d u r in g pneumothorax r e f i l l s ,

e s p e c i a l l y when a d h e s i o n s a r e d i s e a s e - b e a r i n g a r e a s .

P e t e r s and Wooley (1922) and P i sh b e rg (1932)

n o t e t h a t a d h e s i o n s may p r e v e n t s m a l l s u b - p l e u r a l

c a v i t i e s from r u p t u r i n g i n t o t h e p l e u r a l s a c , b u t

i t i s p o s s i b l e t h a t t h e use o f p o s i t i v e p r e s s u r e s

d u r i n g r e f i l l s or o v e r - e x e r t i o n , s u c h a s a bou t o f

c o u g h i n g , may r e s u l t i n th e a d h e s io n s t e a r i n g w i t h th e

c o n s e q u e n t deve lopm ent o f e f f u s i o n and. empyema.

G o o r w i t c h (1943) c o n s i d e r s t h a t empyema f o l lo w s

i n c a s e s o f u n s a t i s f a c t o r y and i n e f f e c t i v e c o l l a p s e ,

due t o m e c h a n i c a l r u p t u r e or t e a r i n g o f a d h e s i o n s .

Weisman (1936) b e l i e v e s t h a t when t u b e r c l e s a r e

p r e s e n t i n t h e base o f th e a d h e s io n s t o th e l u n g ,

r u p t u r e u nde r t h e a c t i o n o f pneumothorax i s t h e most

l i k e l y cau se o f i n f e c t i o n o f th e p l e u r a l s p a c e .

P o s i t i v e p r e s s u r e s and i n j u d i c i o u s r e f i l l s a c t on ly

i n so f a r a s t h e y r u p t u r e a pulmonary l e s i o n bound by

l h 9

a d h e s i o n s . D av ie s ( 1 9 3 3 ) , R o s e n t h a l ( 1 9 3 6 ) , and

L e a v e r and Hardaway ( 1 9 3 7 ) , have e x p r e s s e d s i m i l a r

v i e w s .

M o r r i s o n (19U8) found t h a t o f t h r e e f a c t o r s

r e s p o n s i b l e f o r e f f u s i o n and empyema i n pneumo

t h o r a x , one was t h e use o f p o s i t i v e p r e s s u r e s

d u r i n g r e f i l l s .

A d h es i o n S e c t i o n -

A d h e s io n s e c t i o n , p e r s e , a p p e a r s t o have

b e e n t h e c h i e f c au s e o f empyema i n s e v e n t e e n (2 2 .9 ?0

o f t h e s e v e n t y - f o u r c a s e s o f pneumothorax s u b m i t t e d

t o o p e r a t i o n .

Three o f t h e s e c a s e s had haem othdrax

f o l l o w a d h e s i o n s e c t i o n , w h i le t h r e e o t h e r s s u f f e r e d

t r a u m a t i c b r o n c h o - p l e u r a l f i s t u l a e .

S ix a d d i t i o n a l c a s e s had b r o n c h o - p l e u r a l

f i s t u l a e d e v e lo p w i t h i n s ev en days o f a d h e s io n

s e c t i o n . I f t h e s e c a s e s a r e a l s o t o be a t t r i b u t e d

t o o p e r a t i o n , i t i s p o s s i b l e t h a t t w e n t y - t h r e e

(31.1%) o f t h e s e v e n t y f o u r pneum othoraces

o p e r a t e d upon had empyema o r i g i n a t e from a d h e s io n

s e c t i o n .

G oorw i tch ( l9U 3) c o n s i d e r s t h a t many empyemata

a r e due t o t h e s e v e r i n g o f a d h e s io n s w i th t h e accompany-

150

i n g r u p t u r e o f a pu lm onary l e s i o n . S i m i l a r l y ,

Gloyne (1926) a r g u e s t h a t i f an a d h e s i o n be

s e v e r e d a t a p o i n t a t which t u b e r c l e b a c i l l i c an be

l i b e r a t e d i n t o t h e p l e u r a l c a v i t y , s e c o n d a r y e f f u s i o n

and empyema a r e l i k e l y t o f o l l o w .

R eg a rd in g haemorrhage . fo l lowing a d h e s i o n

s e c t i o n , R a f f e r t y (1944) em p h a s i s e s t h e d a n g e r

where t h e r e i s a l a r g e c a v i t y s i t u a t e d c l o s e t o

t h e p l e u r a suspended by a d h e s i o n s . Much o f th e

b l o o d s u p p l y o f t h e c a v i t y wAll may be d e r i v e d from

i n t e r c o s t a l a r t e r i e s t h r o u g h newly formed v e s s e l s

i n s i d e t h e a d h e s i o n s .

K o ro l (1936) draws a t t e n t i o n t o t h e p o s s i

b i l i t y o f a h aem o r rh a g ic e f f u s i o n a s a r e s u l t o f

b l e e d i n g from t h e stump o f a t o r n a d h e s i o n .

Two c a s e s (2.4%) o f th e s e v e n t y - f o u r c a s e s

o p e r a t e d on had a d h e s i o n s e c t i o n pe r fo rm ed i n

t h e p r e s e n c e o f a c u t e t u b e r c u l o u s pneumonia .

Empyema fo l lo w e d i n f o u r and s even days r e s p e c t i v e l y

f rom t h e d a t e o f o p e r a t i o n .

Nine cases (12,2%) developed empyema w i t h i n

7 -14 days from a d h es io n s e c t i o n and were a p p a r e n t l y

due t o o p e r a t i o n on in f lam ed and tu b e rc u lo u s p l e u r a e .

151

M orrison (1948 ) found th a t o f t h i r t e e n

p a t i e n t s i n whom th e p leu ra was in flam ed a t th e

t im e o f o p e r a t io n , te n d eve lop ed empyema*

The in c id e n c e in t h i s s e r i e s , o f a lm ost

23% o f th e e ig h ty -o n e empyemata being due to a d h es io n

s e c t i o n appears h ig h . M orrison (1 9 4 8 ) , however,

had to r e p o r t th e h ig h in c id e n c e o f 28% o f

empyemata in t h i r t y - s i x o p e r a t io n s as b e in g due

d i r e c t l y to a d h esio n s e c t i o n ,w h i l e Andersen (1 9 4 9 ) ,

r e p o r t in g on 54 c a s e s o f empyema , found th a t

tw e lv e ( 22%) r e s u l t e d from a cu te r e a c t io n f o l lo w in g

c l o s e d p n eu m olys is and 2. 5% fo l lo w e d open pneum olysis .

W oodruff(1938) in a s e r i e s o f c o l l e c t e d c a s e s found

o n ly 5 . 2% o f 154 empyemata which were d i r e c t l y

a t t r i b u t a b l e to a d h esion s e c t io n .

Our r e s u l t s compare more favou rab ly w ith

t h o s e r e p o r te d in th e l i t e r a t u r e when c o n s id e r e d in

com parison w ith th e t o t a l number o f pneumothoraces

rev iew ed . Only 1 .2 % o f empyemata are then due to

a d h e s io n s e c t i o n which compares fa vou rab ly w ith

th e f i g u r e s o f Chandler (1937) 1.9% , o f Anderson

and A lexander (1937)3.6% , Brock (1938)1.4% and

W o lla s to n (1940) 2 %

152

A d h es io n S e c t io n d u rin g E f fu s io n

Jac o b e u s (1922) c o n s i d e r e d t h a t i n p a t i e n t s

h a v i n g a s e r o u s e f f u s i o n p r i o r t o o p e r a t i o n , t h e

o u t l o o k was n o t good because s u c h p l e u r i s i e s u s u a l l y

become w orse a f t e r s u r g i c a l i n t e r f e r e n c e . Benjamin

(1937) a l s o i n s i s t s t h a t a d h e s i o n s e c t i o n sh o u ld not

be p e r f o r m e d d u r in g a c u t e p l e u r i s y , b u t W o l l a s to n (1940)

t h i n k s t h a t t h e s t r e s s imposed on a d i s e a s e d a r e a

o f lu n g by t h e p r e s e n c e o f a d h e s i o n s i s so dan g e ro u s

t h a t t h e p e r fo rm a n c e o f a d h e s i o n s e c t i o n , even

i n t h e p r e s e n c e o f a c u t e e f f u s i o n , i s a j u s t i f i a b l e

r i s k .

I n t h i s p r e s e n t s e r i e s o f t h e t w e n t y - s e v e n

c a s e s w h ic h d e v e lo p e d b r o n c h o - p l e u r a l f i s t u l a and

had a d h e s i o n s e c t i o n ^ t h e o p e r a t i o n was done i n

t h e p r e s e n c e o f u n h e a l t h y p l e u r a e i n tw e lve (44.4%)

R eg a rd in g t h e c a s e s o f empyema w hich d ev e lo p ed

w i t h i n tw e lv e weeks o f o p e r a t i o n , th e p l e u r a was

u n h e a l t h y i n s i x t e e n (66.6%), whereas i n t h o s e c a s e s

i n whom empyema d i d not dev e lo p t i l l be tw een tw e lve

and. f o r t y weeks o f a d h e s i o n th e number found t o

have u n h e a l t h y p l e u r a e was e i g h t , e q u i v a l e n t t o 47%).

153

I t would a p p e a r , a s would be e x p e c t e d ,

t h a t where a number o f c a s e s a r e found a t t h o r a c o s

copy t o have u n h e a l t h y p l e u r a e , a d h e s i o n s e c t i o n

w i l l r e s u l t i n a p r o p o r t i o n a t e l y h i g h e r number o f

empyemata r e s u l t i n g w i t h i n a few weeks o f t h e

o p e r a t i o n . Where t h e r e has been a p r o g r e s s i v e

e f f u s i o n , e s p e c i a l l y i f a s p i r a t i o n was n e c e s s a r y

b e f o r e o p e r a t i o n , empyema may be e x p e c te d t o fo l lo w

i n a b o u t t h e same t ime t h a n as where th e p l e u r a was

u n h e a l t h y a t o p e r a t i o n . On t h e o t h e r hand,

t h e p r e s e n c e o f a s m a l l puddle o f f l u i d i n th e c o s t o -

p h r e n i c a n g l e where th e p l e u r a i s h e a l t h y i s

a p p a r e n t l y o f no s i g n i f i c a n c e .

Development o f e m p y e m a i n t h e s e c a s e s and i n

c a s e s where t h e p l e u r a l space has been d r y up t o

fehe t i m e o f a d h e s i o n s e c t i o n depends on o t h e r f a c t o r s .

C a v i t y C lo s u re a f t e r Adhes ion S e c t i o n

C a v i t y c l o s u r e was o b t a in e d a f t e r a d h e s io n

s e c t i o n i n o n ly f i f t e e n (20.3%) o f t h e s e v e n t y - f o u r

c a s e s s u b m i t t e d t o a d h e s i o n s e c t i o n .

Of t w e n t y - s i x c a s e s c l a s s e d a s s a t i s f a c t o r i l y

c o l l a p s e d , c a v i t y c l o s u r e was o b ta in e d i n e i g h t ( 3 0 , 8 ^ ) .

Of t h e f o r t y - e i g h t c a s e s c l a s s e d a s e i t h e r i n c o m p l e t e ; y

o r i n e f f e c t i v e l y c o l l a p s e d a f t e r a d h e s i o n s e c t i o n ,

c a v i t y c l o s u r e was o b t a in e d i n on ly seven (14.6%).

154

I n o t h e r w o rd s , i n f i f t y - n i n e (79.7%) o f

t h e c a s e s s u b m i t t e d t o a d h e s i o n s e c t i o n , m a in ten an ce

o f pn eu m o th o rax & f t e r o p e r a t i o n f a i l e d t o c o n t r o l

t h e d i s e a s e . A p r o p o r t i o n o f t h e s e c a s e s d e v e lo p e d

b r o n c h o - p l e u r a l f i s t u l a e , a s w i l l be d e s c r i b e d be low .

I f one adds t o t h e f i f t y - n i n e c a s e s i n

w h i c h c a v i t y c l o s u r e was no t o b t a in e d a f t e r a d h e s i o n

s e c t i o n t h e s e v e n c a s e s i n whom a d h e s i o n s were

n o t o p e r a b l e , i t can be s een t h a t o f t h e t o t a l

number o f e i g h t y - o n e pneum othoraces i n which empyema

d e v e l o p e d , d i s e a s e was no t c o n t r o l l e d by th e c o l l a p s e

i n t h e c o n s i d e r a b l e number o f s i x t y - s i x , e q u i v a l e n t t o

8 1 .5 p e r c e n t .

155

B r o n c h o - P l e u r a l F i s t u l a e

T w e n t y - e i g h t (34.6%) o f th e e i g h t y - o n e

empyemata -were due t o known b r o n c h o - p l e u r a l f i s t u l a e .

Nine f i s t u l a e o c c u r r e d w i t h i n one week o f a d h e s i o n

s e c t i o n ; t h r e e o f t h e s e ca s e s were due t o t rauma

a t o p e r a t i o n , f o u r were due t o r u p t u r i n g o f c a v i t i e s ,

w h i l e two f i s t u l a e r e s u l t e d from r u p t u r i n g o f su.b-

p l e u r a l f o c i t h r o u g h t u b e r c u l o u s p l e u r a e .

Type o f C o l l a p s e i n c a se s o f B r o n c h o - P le u r a l F i s t u l a .

Nine c a s e s o f f i s t u l a o c c u r re d i n c a s e s

s a t i s f a c t o r i l y c o l l a p s e d , b u t i n o n ly one o f t h e s e

c a s e s was c a v i t y c l o s u r e o b t a i n e d . T h is p a t i e n t

had a p l e u r a w h ich was found a t th o r a c o s c o p y t o be

s t u d d e d w i t h m u l t i p l e t u b e r c l e s . F i s t u l a from

r u p t u r e o f a s u b - p l e u r a l focus o cc u r re d a t 16 weeks

from o p e r a t i o n .

Ten f i s t u l a e o c c u r re d i n c a s e s i n c o m p l e t e l y

c o l l a p s e d and e i g h t i n c a s e s i n e f f e c t i v e l y c o l l a p s e d .

I n none o f t h e s e c a s e s was c a v i t y c l o s u r e o b t a i n e d .

I n a l l n i n e t e e n o f t h e t o t a l number o f

t w e n t y - e i g h t , f i s t u l a e o c cu r re d from r u p t u r i n g o f

c a v i t i e s o f t h e " b a l l o o n i n g " t e n s i o n t y p e .

Four c a s e s were due t o r u p t u r e o f sub —

p l e u r a l f o c i t h r o u g h t u b e r c u l o u s p l e u r a e * t h r e e

156o t h e r c a s e s were t r a u m a t i c , and one case occurred,

a f t e r f o u r months t r e a t m e n t o f e f f u s i o n and m a i n t e n

an ce o f c o l l a p s e by o l e o t h o r a x .

B r o n c h o - p l e u r a l f i s t u l a o c c u r r e d i n one

p a t i e n t who was no t s u b j e c t e d t o a d h e s i o n s e c t i o n .

He had had a pneumothorax induced w h i l e s u f f e r i n g

f rom a c u t e t u b e r c u l o u s pneumonia . T horacoscopy

was p e r f o r m e d , b u t th e a d h e s io n s were found t o be

i n o p e r a b l e . F i s t u l a i n t h i s case o c c u r r e d tw e lv e

weeks a f t e r i n d u c t i o n o f th e pneum othorax .

.Five c a s e s w hich d ev e lo p ed b r o n c h o - p l e u r a l

f i s t u l a d e v e lo p e d complete a t e l e c t a s i s o f th e lung

a t v a r y i n g i n t e r v a l s a f t e r a d h e s io n s e c t i o n and p r io r ,

t o c a v i t y r u p t u r e t a k i n g p l a c e .

Causes of F i s t u l a i n t h e s e tw e n ty -e ig h t c a s e s .

A d h e s io n s e c t i o n i s known d e f i n i t e l y t o

have cau sed t h r e e f i s t u l a e , b u t i t i s d i f f i c u l t

t o e x o n e r a t e t h e e f f e c t s o f o p e r a t i o n i n t h e o t h e r

s i x c a s e s w h ic h o c c u r r e d w i t h i n one week o f a d h e s i o n

s e c t i o n .

R eg a rd in g th e c a se s o f r u p t u r e d c a v i t y ,

R a f f e r t y (1944) l i s t s i n t e r a l i a two t y p e s o f case

w h i c h a r e u n s u i t a b l e f o r pneumothorax t r e a t m e n t

b e c a u s e o f t h e d a n g e r o f empyema, T re se a r e : -

157

1 . Cases o f l a r g e a p i c a l c a v i t y ;

2 . Cases o f e n d o - b r o n c h i a l t u b e r c u l o s i s .

I n t h i s s e r i e s , n i n e t e e n c a se s (2 3 .5 ^ ) o f

t h e t o t a l . n u m b e r o f empyemata had pneumothorax

i n d u c e d i n t h e p r e s e n c e o f a l a r g e a p i c a l c a v i t y .

S tu d y o f t h e X -rays o f t h e s e c a s e s would

s u g g e s t t h a t :

1 . Pneumothorax shou ld not have been t h e t r e a t

ment o f c h o i c e , and

2 . The pneum othoraces shou ld have been abandoned

(a ) b e c a u s e t h e m a j o r i t y were in co m p le te or i n e f f e c t

i v e , and (b) b e ca u se t h e c a v i t y i n e a c h case was o f

t h e d a n g e r o u s b a l l o o n i n g t e n s i o n t y p e .

R e g a rd in g t h e f i v e c a s e s w h ich d ev e lo p e d

c o m p le te a t e l e c t a s i s a f t e r a d h e s io n s e c t i o n . Bron

c h o s c o p y was no t p r a c t i s e d r o u t i n e i n t h e S a na to r ium

d u r i n g t h e p e r i o d u nder r e v i e w , a l t h o u g h no doubt

t h e s e p a t i e n t s p r e s e n t e d p h y s i c a l s i g n s o f t u b e r

c u l o u s b r o n c h i t i s . Such e n d o - b r o n c h i a l d i s e a s e

may have a c t e d i n two ways; on th e one hand i t may

have b e e n t h e cause of a ch eck -v a lv e mechanism

d e v e l o p i n g , w i t h co n seq u en t ,rb a l l o o n i n g o f t e n s i o n

c a v i t i e s , and on th e o t h e r hand may have been th e

p r e c u r s o r o f t h e comple te a t e l e c t a s i s .

158

D i s c u s s i n g t h e r e l a t i o n s h i p o f b r o n c h o

p l e u r a l f i s t u l a t o t h e o c c u r re n c e o f empyema,

C o r y l l o s (1937) i s o f t h e o p in io n t h a t a l l e f f u s i o n s

and. empyemata d u r in g pneumothorax t r e a t m e n t a r e

due t o t h e d e v e l o p i n g o f l a r g e , medium, or p u n c t i f o r m

f i s t u l a e , w h i l e P e t r o f f , Herman & B a l i t z (1 9 4 1 ) , i n

t h e i r f i r s t s e r i e s o f c a s e s , found b r o n c h o —p i e u r a l

f i s t u l a r e s p o n s i b l e f o r 75%, and i n a second s e r i e s

f o r 100% o f empyemata, 61 % o f t h e f i s t u l a e hav ing

o c c u r r e d s p o n t a n e o u s l y , 39% f o l lo w in g a d h e s io n

s e c t i o n . I n my s e r i e s i t i s p ro b a b le t h a t n i n e

c a s e s (32.1%) were due t o a d h e s i o n s e c t i o n .

Simmonds (1941) has s u g g e s t e d t h a t r u p t u r e o f a c a v i t y

i s a l m o s t t h e s o le cause o f e f f u s i o n and eimpyema i n

a r t i f i c i a l pneum othorax , w h i le Pen ing ton , (1939)

i n h i s e x p e r i m e n t s on r a b b i t s showed t h a t a l l t h e

c a s e s w h i c h d e v e lo p e d empyema a f t e r pneumothorax

showed m i c r o s c o p i c ev id e n c e o f r u p t u r e o f a sub-

p l e u r a l i n t r a - p u l m o n a r y f o c u s . The m a j o r i t y o f

s u c h f o c i w h ic h r u p t u r e d t h r o u g h t h e p l e u r a were w e l l

l o c a l i s e d l e s i o n s w hich p ro c e ed ed t o c a v i t y f o r m a t i o n .

Gordon e t a l (1943) found t h a t t u b e r c u l o u s

em p yem a fo l l o w e d r u p t u r e o f a caseous nodule which

t h e y c o n s i d e r a r e more common on t h e f r o n t o f th e

lung and t h e g r e a t e r movement o f th e a n t e r i o r c h e s t

159

p r e d i s p o s e s t o t h e i r r u p tu r e * I have no e v i d e n c e

t o c o n f i r m t h i s l a t e r o b s e r v a t i o n , b u t t h e i r f i r s t

o b s e r v a t i o n and t h o s e o f Simmonds ( l9 U l) and

P e n i n g t o n (1939) have b e e n co n f i rm ed i n my s e r i e s

o f c a s e s .

I t would a p p ea r t h a t t h e r e i s e v id e n c e f o r

a b a n d o n i n g pneum othorax n o t o n ly when a l a r g e

t e n s i o n c a v i t y d e v e l o p s , a n d when t h e c o l l a p s e i s n o t

a c h i e v i n g c a v i t y c l o s u r e th ro u g h i t s b e i n g in c o m p le te

o r i n n e f f e c t i v e , b u t a l s o when a t u b e r c u l o u s p l e u r a

i s fo u n d a t t h o ra c o sc o p y .

I t h as b ee n s u g g e s t e d e a r l i e r t h a t c a s e s i n

w hich c o m p le t e a t e l e c t a s i s o c c u r s a f t e r a d h e s io n

s e c t i o n s h o u l d a l s o have t h e i r pneum othoraces

abandoned f o r t h w i t h .

160

Summary o f E t i o l o g y

The p r i n c i p a l c au s e s of* empyema i n

t h i s s e r i e s o f c a s e s would a p p e a r t o have b e e n ,

i n o r d e r o f i m p o r t a n c e , -

1* C o l l a p s e by pneumothorax o f c a s e s u n s u i t a b l e f o r s u c h t r e a t m e n t by r e a s o n

i . Acute a c t i v i t y o f t h e d i s e a s e ;

i i . The ty p e o f l e s i o n .

2 . M ain tenance o f in co m p le te and d e - s e l e c t i v e pneum othoraces* a n a ,m o s t i m p o r t a n t , t h o s e w i t h p e r s i s t e n t c a v i t a t i o n .

3 . A d h e s io n s e c t i o n .

4 . B r o n c h o - p l e u r a l f i s t u l a .

5 . M a in ten a n ce o f c o l l a p s e a f t e r developmento f com ple te a t e l e c t a s i s and by t h e use o fp o s i t i v e i n t r a - p l e u r a l p r e s s u r e s .

R eg a rd in g t h e p r e v e n t i o n o f empyema i n

c o m p a ra b le c a s e s . I t would a p p e a r t h a t t h e ff .

c h o i c e o f case f o r pneumothorax t r e a t m e n t should j _n<\l

/

r i g i d l y e x c lu d e th o s e t y p e s l i s t e d i n Tab le 18.

W i th t h e r e c o g n i t i o n o f th e f a c t t h a t a lm o s t

a l l c a s e s o f parenchym al t u b e r c u l o s i s have a s s o c i a t e d

e n d o - b r o n c h i a l d i s e a s e o f g r e a t e r or l e s s deg ree o f

161s e v e r i t y , t h e r e would seem t o be a p l a c e f o r

r o u t i n e b ro n c h o c o sc o p y b e f o r e and a f t e r i n d u c t i o n

o f p n e u m o th o ra x , e s p e c i a l l y now, when t h i s t y p e o f

d i s e a s e i s known t o re sp o n d w e l l t o s t r e p t o m y c i n

t r e a t m e n t •

A l t e r n a t i v e t r e a t m e n t f o r p a t i e n t s w i t h

d i s e a s e u n s u i t a b l e f o r pneumothorax t r e a t m e n t has

b e e n made a v a i l a b l e t o a g r e a t e r e x t e n t now, w i t h

t h e d i s c o v e r y o f s t r e p t o m y c i n and p a r a - a m in o

s a l i c y l i c a c i d , and th e advances i n t h o r a c i c s u r g e r y .

So f a r a s a c t i v i t y o f d i s e a s e i s concerned

a t t h e t im e o f i n d u c t i o n o f p n eum othora x , t h e

s h o r t a g e o f beds a t t h e p r e s e n t t ime has not made

e a s i e r t h e o p p o r t u n i t y o f a l l o w i n g a p a t i e n t p r o lo n g e d

bed r e s t p r i o r t o i n d u c t i o n o f pneum othorax . To

com pensa te f o r t h i s d e f i c i e n c y , and i n o r d e r t o

r e d u c e a c t i v i t y o f d i s e a s e , t h e r e seems a p l a c e f o r

pneum o-per i toneum ' w i t h o r w i th o u t p h r e n i c c r u s h f o r a

p r e l i m i n a r y p e r i o d t o a l l o w th e d i s e a s e t o ,fc o o l o f f " .

Pneumothoraces w h ic h canno t be r e n d e r e d s a t i s

f a c t o r y by a d h e s i o n s e c t i o n sh o u ld be abandoned a t

t h e t im e o f o p e r a t i o n .

S a t i s f a c t o r y a n a t o m i c a l c o l l a p s e s , where

t h e y a r e no t a c h i e v i n g c a v i t y c l o s u r e , might r e a s o n a b l y

162be a bandoned and a l t e r n a t i v e t r e a t m e n t c o n s id e r e d .

A dhes ion s e c t i o n w i l l i n e v i t a b l y c a r r y a

r i s k o f p o s t - o p e r a t i v e c o m p l i c a t i o n s . The o p e ra b

i l i t y or o th e rw ise o f a d h es io n s and th e e x t e n t

o f a r e a t o be c a u t e r i z e d must be l e f t t o t h e judg

ment o f t h e o p e r a t o r .

B r o n c h o - p l e u r a l f i s t u l a should be a v o i d

a b l e by o b s e rv in g the p r i n c i p l e s mentioned a l r e a d y ,

r e g a r d i n g ch o ice o f case f o r pneumothorax and main

t e n a n c e o f c o l l a p s e . Col lapse should not be

i n d u c e d u n l e s s a d h e s io n s e c t i o n f a c i l i t i e s a r e

a v a i l a b l e , and th e o p e r a t io n can be performed i n a

r e a s o n a b l y s h o r t t ime a f t e r i n d u c t i o n . P o s i t i v e

p r e s s u r e s sh o u ld not be used t o m a in ta in c o l l a p s e .

Regarding the development o f complete

a t e l e c t a s i s i t has a l r e a d y been sugges ted t h a t

c a s e s i n w h ic h t h i s occurs should have t h e i r pneumo

t h o r a x abandoned d e s p i t e complete r e - a e r a t i o n i n a

s h o r t t i m e .

163

DISCUSSION

T r e a t m e n t and R e s u l t s

G e n e r a l l y , t r e a t m e n t o f b o t h p u re and mixed

t y p e s o f t u b e r c u l o u s empyema can be d i v i d e d i n t o

two b r o a d c l a s s e s -

1 , C o n s e r v a t i v e ;

2 , R a d i c a l o r s u r g i c a l .

C o n s e r v a t iv e t r e a t m e n t may ra n g e f rom " w a t c h

f u l n e g l e c t " t h r o u g h t h e d i f f e r e n t s t a g e s o f a s p i r a t i o n ,

t o p l e u r a l l a v a g e w i t h a n t i s e p t i c s and i n s t i l l a t i o n o f

d r u g s i n t o t h e empyema s p a c e .

R a d i c a l t r e a t m e n t c o v e r s a l l t h e m ajor

s u r g i c a l p r o c e d u r e s , s u c h a s t h o r a c o p l a s t y , w i t h or

w i t h o u t d e c o r t i c a t i o n o f t h e l u n g , e x t r a p l e u r a l plombage

w i t h p l a s t i c p o l y t h e n e pack and more r e c e n t l y p l e u r o -

pne umone c t omy.

H i t h e r t o , t h e p r e s e n c e o f s e c o n d a ry p yogen ic

i n f e c t i o n v a s t l y a l t e r e d t h e fu n d a m e n ta l a p p r o a c h t o

t r e a t m e n t , b u t t h e a v a i l a b i l i t y o f p e n i c i l l i n and

o t h e r a n t i b i o t i c s has a l l o w e d t h e t r e a t m e n t o f b o t h

p u r e and mixed empyemata, a t l e a s t i n t h e e a r l y

s t a g e s , t o p ro c e e d on more or l e s s i d e n t i c a l l i n e s .

164

Dure T u b ercu lou s Smoyema.

" H atchfu l n e g le c t" or a d o p tio n o f the

a t t i t u d e t h a t most ca se s o f tu b e r c u lo u s empyema are

b e s t t r e a t e d by no trea tm en t has been ad vo ca ted in

th e p a s t by the Committee o f th e American Sanatorium

A s s o c i a t i o n (1 9 3 1 ) , by Chandler (1 9 4 2 ) , O rn ste in &

Ulmar ( 1 9 3 9 ) , D uboff (1919) and C o r y llo s ( 1 9 3 7 ) .

U s h b e r g (1932) contends th a t t h i s type o f "treatm ent"

may be used o c c a s i o n a l l y , but 'Voodruff ( 1 9 3 8 ) , i n an

acco u n t o f 154 c a se s o f tu b e r c u lo u s empyema, observed

over a p er io d vary in g from th r e e t o e i g h t y e a r s ,fo u n d o n ly

s i x c a s e s i n ?/hich no a c t i v e trea tm en t was g i v e n .

Of t h e s e s i x c a s e s , two were d ead , two were a l i v e ,

but were i n v a l i d s , and two were w e l l and w ork in g ,

f i c k e y (1943) s t a t e s t h a t in h i s e x o e r ie n c e , c a s e s

s u c c e s s f u l l y " treated" by doing n oth in g are very few

ana t h a t sooner or l a t e r txiu vast m a jo r ity d ev e lo p

b r o n c h o -p le u r a l f i s t u l a e or p le u r o -c u ta n e o u s s i n u s e s .

Skavlem e t a l (1 9 4 0 ) , in a r ep o r t on treatm en t o f

tu b e r c u lo u s empyema, found th a t w i t h what th e y termed

" i n d i f f e r e n t treatm en t c o n s i s t in g o f bed r e s t , o p ia te s

and o c c a s io n a l a s p i r a t i o n , f o r t y out o f a t o t a l o f

f o r t y - o n e p a t ie n t s s u b je c te d t o t h i s regim e d ied i n

h o s p i t a l .

165

In my s e r i e s o f s e v e n t y - e i g h t p a t i e n t s ,

none were t r e a t e d hy " w a tch fu l n e g l e c t " . C o n se r v a t iv e

tr e a tm e n t was used i n s i x t y - n i n e p a t i e n t s ( 8 8 . 5 $ ) .

As has been p o in te d out i n S e c t io n I , Table 1 6 , o n ly

two ( 2 .5 $ ) o f th e s e v e n t y - e i g h t p a t i e n t s had a c o n t r a

l a t e r a l lung c l e a r o f d i s e a s e a l th o u g h tw en ty (2 6 .3 $ )

o f th e rem ain ing s e v e n t y - s i x p a t i e n t s had a minimal

d eg ree o f c o n t r a l a t e r a l d i s e a s e . I t i s not s u r p r i s i n g ,

t h e r e f o r e , t o f in d t h a t o n ly n ine p a t i e n t s ( 1 1 .5 $ )

o f th e t o t a l o f s e v e n t y - e i g h t were t r e a t e d by t h o r a

c o p la s t y ; in d e e d , t h i s i s a f a i r l y h ig h p r o p o r t io n

fo r i t means th a t a number o f p a t ie n t s w i th c o n t r a

l a t e r a l d i s e a s e w e r e , i n f a c t , t r e a t e d s u r g i c a l l y

and th e r e s u l t s , a s shown i n Table 48 , seem t o have

j u s t i f i e d th e r i s k .

I t would a p p ea r , t h e r e f o r e , t h a t i n t h i s

s e r i e s , c o n s e r v a t iv e trea tm en t (as th e f i n a l form o f

t r e a tm e n t ) was adopted because th e r e was no a l t e r n a t i v e .

In t h e s e p a t i e n t s , t h e r e f o r e , no r e a l permanent c o n t r o l

o f th e u n d e r ly in g lung d i s e a s e was a t te m p te d , a l th o u g h

i n 25 p a t i e n t s th e pneumothorax was m a in ta in e d , a s

shown i n Table 78.

I t i s s u r p r i s i n g , t h e r e f o r e , t o f in d th a t

i n Group A (pure tu b e r c u lo u s empyema) o f t h i r t y - n i n e

166

p a t i e n t s t r e a t e d c o n s e r v a t i v e l y , s e v e n te e n (4 3 .6 ^ )

are a l i v e . S u r v iv a l i n some o f t h e s e c a s e s has

b een t e n y e a r s and e i g h t - y e a r s down t o 3-J- t o 4 y e a r s ,

w h ich was th e maximum p o s s i b l e s in c e o n se t o f th e

empyema.

In Group B (th e p y o g e n ic a l ly i n f e c t e d group

o f em pyemata), t h i r t y p a t i e n t s , i n v o lv in g t h i r t y - t w o

empyemata, were t r e a t e d by c o n s e r v a t iv e methods and

o n ly sev en ( 2 3 .3 $ ) are a l i v e .

I n d i v i d u a l Methods o f T re a tm en t .

1 . A s p ir a t io n and A ir r ep la cem en t -

This was the s im p le s t trea tm en t a d o p te d ,

where a ttem p t was b e in g made (not n e c e s s a r i l y w i s e l y )

t o m a in ta in th e pneumothorax.

In Group A, s e v e n te e n c a s e s were t r e a t e d

by t h i s m ethod. Of t h e s e , sev e n ( 4 1 .2 $ ) are a l i v e ,

nine (5 2 .9 $ ) are dead , and one ca se ( 5 .9 $ ) was l o s t

s i g h t o f .

In Group B th e r e were o n ly s i x c a s e s w hich

in c lu d e d sev en empyemata, i n th a t one p a t ie n t had

b i l a t e r a l empyema. Of t h e s e s i x p a t i e n t s fou r (6 6 .6 $ )

are d ea d , and two (3 3 .3 $ ) were l o s t s ig h t o f .

Ib7

Of th e t o t a l number o f t w e n ty - th r e e c a s e s ,

In b o th groups t r e a t e d by t h i s m ethod, se v e n ( 3 0 .4 $ )

are a l i v e , t h i r t e e n ( 5 6 .5 $ ) a re d e a d , and th r e e ( 5 .1 $ )

a re l o s t s i g h t o f .

Of th e sev en p a t i e n t s i n Group A who are

a l i v e and were t r e a t e d by t h i s m ethod, fo u r had

u n i l a t e r a l pneumothoraces and th r e e b i l a t e r a l pneumo

t h o r a c e s . S ix p a t i e n t s are w e l l and working (two

w i t h re -exp an d ed c o n t r a l a t e r a l pneumothoraces ) , w h ile

one I s not w e l l nor w ork in g . S u r v iv a l from o n se t o f

empyema i n th e s e sev en p a t i e n t s v a r i e s from 8-| y e a r s

t o th e maximum p o s s i b l e o f 4 y e a r s .

These r e s u l t s compare not u n fa v o u ra b ly

w it h th o s e o f W oodruff (1 9 3 8 ) , who found t h a t o f t h i r t y -

e i g h t p a t i e n t s i n Group A t r e a t e d by s im p le a s p i r a t i o n

and a i r rep la cem en t and s tu d ie d over a p e r io d o f from

th r e e t o e i g h t y e a r s , tw e n ty - th r e e (6 0 .5 $ ) have s u r

v iv e d and f i f t e e n (3 9 .5 $ ) are d ea d .

Of th e tw e n ty - th r e e s u r v i v a l s , f i f t e e n

(6 5 .2 $ ) are w e l l and working and e ig h t (3 4 .8 $ ) are

not w e l l nor w o rk in g .

Of s i x p a t i e n t s in Woodruff Ts Group 3

( s e c o n d a r i ly i n f e c t e d c a s e s ) f iv e (8 3 .3 $ ) are d ea d .

One p a t ie n t i s a l i v e , but i s not a b le t o work.

168

^ • A s p ir a t io n ana Pl e u r a l Lavage w i t h A n t i s e p t i c s

and D y e s .

The Committee o f th e American Sanatorium

A s s o c i a t i o n (1931) r e p o r te d t h a t most san a to r iu m

p h y s ic ia n s were o f th e o p in io n t h a t i n t r a p l e u r a l

i n j e c t i o n o f c h e m ic a l s o l u t i o n s seemed t o be o f more

use th a n a i r rep la cem en t a l o n e , but was o f l i t t l e

v a lu e i n th e s u c c e s s f u l tr ea tm en t o f empyema.

In th e p y o g e n ic a l ly i n f e c t e d c a s e s i t was th ou gh t

t h a t c h e m ic a l s o lu t i o n s might be used i n a t te m p ts

t o s t e r i l i z e th e p l e u r a l c a v i t y , but no p a r t i c u l a r

c h e m ic a l co u ld be recommended. T h is l a t t e r c o n t e n t

i o n i s sup p orted by r e p o r t s in th e l i t e r a t u r e o f

e x p er im en ts w i t h a l l manner o^ s o l u t i o n s su c h as

g e n t ia n v i o l e t , a c r i f l a v i n e , mercurochrome, m ethylene

b l u e , b r i l l i a n t g r e e n , and many o t h e r s . T h e ir very

number and v a r i e t y were p ro o f o f t h e i r i n e f f i c a c y .

F ollow ing r e p o r t s on A zo-ch loram ia and sodium

t e t r a - d e c y l s u lp h a te ( Azo T . ) by P e t r o f f , Herman

and P a l i t z (1941) and Munro-Ashman & Tate (1943)

t h i s s o l u t i o n was adopted by th e C heshire J o in t

Sanatorium fo r r o u t in e use i n tu b e r c u lo u s empyema.

Azo T. s o l u t i o n a l o n e , or i n com bination

w it h one or o th er s o l u t i o n su ch as e n s o l , normal

s a l i n e , m ethylene b l u e , a c r i f l a v i n e and Carre 1-Dakin

169s o l u t i o n was used i n tw e n ty - th r e e ( 2 9 .5 $ ) o f th e

s e v e n t y - e i g h t p a t i e n t s .

S e v e n te e n ( 7 3 .9 $ ) o f t h e s e t w e n ty - th r e e

c a s e s were i n Group A and s i x (2 6 .1 $ ) were i n Group B

Of th e s e v e n te e n Group A c a s e s , s e v e n (4 1 .2

are a l i v e , n ine (5 2 .9 $ ) are d e a d , and one case ( 5 .9 $ )

was l o s t s ig h t o f . These r e s u l t s a r e s im i l a r t o

th o s e o b ta in e d i n c a s e s t r e a t e d by s im p le a s p i r a t i o n

and a i r rep la cem en t o n ly ^ w ith e q u a l numbers o f

p a t i e n t s . A l l s e v e n s u r v iv o r s i n Group A a r e w e l l

and w o rk in g , tw 0 having su r v iv e d t e n y ea r s from

o n se t o f empyema and th e o th e r s vary in g p e r io d s uo

t o th e maximum p o s s i b l e o f fou r y e a r s . One p a t i e n t

who had a c o n t r a l a t e r a l pneumothorax has su r v iv e d

s i x y e a r s •

In Group 8 , o f a t o t a l number o f s i x

c a s e s t r e a t e d by t h e s e m ethods, fou r (6 6 .6 $ ) are

d e a d , one case i s a l i v e and one was l o s t s i g h t o f .

W oodruff (1938) r e p o r te d on s e v e n t y - s i x

c a s e s t r e a t e d by th e above methods . F o r ty - th r e e

(5 6 .6 $ ) were i n Group A, and t h i r t y - t h r e e (4 3 .4 $ )

were i n Group B. His r e s u l t s w e r e : -

170

Group A Cases - t o t a l number f o r t y - t h r e e .

A l i ve - t w e n t y - e i g h t (65$), o f whom f o u r t e e n (50$)

were w e l l and w o r k i n g .

Dead - f i f t e e n ( 3 5 .1 $ )

Group B - t o t a l number t h i r t y - t h r e e .

A l i v e - f o u r t e e n (42.4%) o f whom f i v e a r e w e l l and

w o rk in g •

Dead - n i n e t e e n ( 5 7 . 6 $ ) .

My r e s u l t s compare w i t h t h e s e a s f o l l o w s : -

Group A - T o t a l number s e v e n t e e n .

A l i v e - s e v e n ( 4 1 .2 $ )

Dead - n i n e ( 5 2 .9 $ )

Lost s i g h t o f - one ( 5 .9 $ )

Group B - T o t a l number s i x .

A l i v e - one ( 1 6 . 7 $ ) .

Dead - f o u r ( 6 6 .6 $ )

Lost s i g h t o f - one ( 1 6 ,7 $ )

I t would a p p e a r , a s would be e x p e c t e d ,

t h a t s u r v i v a l d ep en d s i n t h e f i r s t p l a c e , i n m a i n t a i n

in g f reed o m f rom s e c o n d a r y i n f e c t i o n i n t h e p l e u r a l

s p a c e •

My own r e s u l t s and t h o s e o f W oodru ff a l r e a d y

q u o t e d , s u g g e s t t h a t i n Group a c a s e s a s p i r a t i o n

171

f o l l o w e d by l a v a g e lias l i t t l e i f a n y a d v a n t a g e t o

o f f e r compared w i t h t r e a t m e n t by s im p le a s p i r a t i o n

and l a v a g e w i t h Azo T a l o n e or i n c o m b i n a t i o n w i t h

o t h e r s o l u t i o n s .

R e p o r t s o f t r e a t m e n t by a s p i r a t i o n and

l a v a g e found i n t h e l i t e r a t u r e shew c o n f l i c t i n g

v iew s and v a r y i n g r e s u l t s .

Jones and A le x a n d e r (1934) s t a t e t h a t

" r e l i a n c e upon n o t h i n g b u t p r o l o n g e d a s p i r a t i o n s

w i t h o r w i t h o u t a n t i s e p t i c i r r i g a t i o n s o r i n s t i l l a t

i o n s . . . . i n e v i t a b l y r e s u l t * i n a s h o c k i n g l y h i g h

m o r t a l i t y . " These w o r k e r s r e p o r t o f f i v e c a s e s

t h e y t r e a t e d b y t h e s e methods and a l l d i e d .

Gordon, Char r & Sava cod ( 1 9 4 3 ) , on t h e o t h e r

h a n d , s p e a k w e l l o f r e p e a t e d a s p i r a t i o n a n d i r r i g a t i o n

w i t h n o rm a l s a l i n e i n pure t u b e r c u l o u s empyema.

They q u a l i f y t h e i r r e m a r k s , how ever , by s u g g e s t i n g

t h a t s u c c e s s can o n ly be e x p e c t e d i f t h e l e s i o n i n

t h e lung i s w e l l c o n t r o l l e d . I t 'would a p p e a r

t h a t one s h o u ld r e a s o n a b l y no t e x p e c t empyema t o

d e v e l o p i n c a s e s o f pneum othorax where t h e pu lm o n ary

l e s i o n i s c o n t r o l l e d .

C u t l e r (1941) r e p o r t e d good r e s u l t s a l s o w i t h

a s p i r a t i o n an d i r r i g a t i o n w i t h n o rm a l s a l i n e . C o e l l o

(1947) c o n s i d e r s i t i s j u s t i f i a b l e t o s t a r t t r e a t m e n t

172

by a s p i r a t i o n a l o n e o r a s p i r a t i o n and l a v a g e s ,

b u t t h i s t r e a t m e n t s h o u ld no t be p e r s i s t e d i n . t o o

long f o r t h e g r a d u a l t h i c k e n i n g o f t h e p l e u r a may

r e n d e r t h e f i n a l t h o r a c o p l a s t y t o o e x t e n s i v e o r t o o

t r a u m a t i c . T h i s would s u g g e s t t h a t t h e w r i t e r

E n v i s a g e s t h o r a c o p l a s t y a s i n e v i t a b l e i n t h e f i n a l

e v e n t .H e a f & Rusby (1948) s t a t e t h a t p l e u r a l

a s p i r a t i o n and l a v a g e w i l l c l e a r l y g i v e t h e b e s t

r e s u l t s i n t h o s e p a t i e n t s i n whom empyema o c c u r s

l a t e i n t h e c o u r s e o f pneum othorax t r e a t m e n t , f o r

b y t h i s t im e t h e pu lm onary l e s i d n w i l l p r o b a b l y have

h e a l e d .

TToyle (1943) t a k e s t h e o p p o s i t e view and.

d o u b t s w h e th e r l a v a g e does a n y t h i n g more t h a n c l e a n

t h e p l e u r a l s p a c e . He c o n te n d s t h a t t h e r e i s

n o t h i n g i n t h e p h a rm ac o lo g y o f t h e many a n t i s e p t i c s

u s e d f o r l a v a g e t o s u g g e s t t h a t a n y o f them can

c o n t r o l t h e t u b e r c u l o u s p r o e e s s ^ a n d e v e n i f t h e y

c o u l d , i t i s d i f f i c u l t t o see how s u c h a n a c t i o n

c o u l d be b r o u g h t t o b e a r on t h e d e p t h s o f t h e p l e u r a

where i t i s most w a n t e d , m e r e ly b y s u r f a c e l a v a g e .

But a s p i r a t i o n w i t h or w i t h o u t l a v a g e , n e v e r t h e l e s s ,

i s an e f f e c t i v e measure f o r t h e c o n t r o l o f to x a e m ia and

173

f o r a s s i s t i n g r e - e x p a n s i o n o f t h e l u n g . Only

i n d i r e c t l y i n t h i s way d o e s i t a f f e c t t h e u l t i m a t e

outcome f o r t h i s d e p e n d s ' o n o t h e r t h i n g s .

3 • A s p i r a t i o n la v a g e and I n j e c t i o n o f Su lphonam ide

Powder or P e n i c i l l i n i n S a l i n e I n t r a p l e u r a l l y .

S ix c a s e s , a l l i n Group B, were t r e a t e d

b y l a v a g e w i t h Azo T s o l u t i o n , no rm a l s a l i n e s u p p l e

mented b y i n j e c t i o n s o f su lp h o n a m id e powder i n s a l i n e ,

o r p e n i c i l l i n i n t r a p l e u r a l l y .

Pive o f t h e s e s i x c a s e s a r e d ead and o n l y

one i s a l i v e . T h i s p a t i e n t has s u r v i v e d 3-J- y e a r s

f rom t h e o n s e t o f empyema, b u t i s n o t w e l l n o r w o r k i n g .

Of t h e f i v e who d i e d , one s u r v i v e d 4 y e a r s

and a n o t h e r two y e a r s and n in e m o n t h s . The r e m a i n d e r

d i e d w i t h i n a m a t t e r o f months from t h e o n s e t o f

empyema. T h e re i s no d o u b t t h e a d d i t i o n o f

s e c o n d a r y i n f e c t i o n c a r r i e s a v e r y h i g h m o r t a l i t y .

Three case s which r e c e i v e d p e n i c i l l i n

c l e a r e d t h e i r i n f e c t i o n : ' none o f th o se w h ich r e c e i v e d

sulphonamide powder c l e a r e d t h e i r secon d a ry i n f e c t

i o n .

174

4 . A s p i r a t i o n l a v a g e and F i n a l C lo s e d D r a i n a g e .

S i g h t p a t i e n t s were t r e a t e d b y t h e s e m ethods

a s t h e f i n a l fo rm o f t r e a t m e n t . Seven ( 8 7 .5 $ )

a r e d e a d . The p a t i e n t who h a s s u r v i v e d has l i v e d

s e v e n a n d a h a l f y e a r s f rom o n s e t o f h i s empyema and

i s now w e l l and w o r k i n g . A s u r p r i s i n g f e a t u r e o f

t h i s m an’s c a s e i s t h a t t u b e d r a i n a g e was c o n t i n u e d

f o r a s long a s t h i r t e e n m o n t h s , w h i l e a t t h e same t im e

he had a c o n t r a - l a t e r a l p n e u m o th o ra x .

V a r io u s s o l u t i o n s , s u c h a s Azo T , 1 /2000 f l a v i n e ,

n o rm a l s a l i n e , and su lp h o n am id e powder i n cod l i v e r o i l

were u sed f o r i n t r a p l e u r a l l a v a g e and i n j e c t i o n i n

t h e s e c a s e s . Four o f t h e s e e i g h t p a t i e n t s had b r o n c h o

p l e u r a l f i s t u l a e . Of t h e s e v e n c a s e s w h i c h a r e d e ad

s i x d i e d w i t h i n s i x t o e i g h t e e n months o f t h e i n s t i t u t

i o n o f t u b e d r a i n a g e . The o t h e r c a s e had h i s t u b e

i n s e r t e d a s an o u t - p a t i e n t and no r e c o r d i s a v a i l a b l e ,

o f when t h i s was done . He s u r v i v e d i n a l l 5-J- y e a r s

f rom o n s e t o f empyema.

The h i g h m o r t a l i t y r a t e i n my s e r i e s o f

p a t i e n t s t r e a t e d b y t h e s e methods compares u n f a v o u r a b l y

w i t h t h e r e s u l t s r e p o r t e d by W o o d ru f f ( 1 9 3 8 ) . His

s e r i e s i n c l u d e d t h i r t y - t h r e e p a t i e n t s t r e a t e d by

t u b e d r a i n a g e , o f whom t w e n t y - o n e (63 .6 j f ) were r e p o r t e d

175

a s d e a d . Of t h e r e m a i n i n g t w e l v e p a t i e n t s , o n l y

t h r e e w ere w e l l and t h e y had had t h o r a c o p l a s t y a s

t h e i r f i n a l t r e a t m e n t .

A l l W o o d ru f f ’ s c a s e s were f o l l o w e d up f o r

p e r i o d s o f f rom t h r e e t o e i g h t y e a r s .

D a v id s o n (1941) i n s t i t u t e d t u b e d r a i n a g e

a s a f i r s t s t e o i n t r e a t m e n t i n 125 c a s e s . T h i r t y -

e i g h t c a s e s who had t h i s a s t h e i r o n l y form o f t r e a t

ment were a l l r e p o r t e d t o be' dead i n a r e l a t i v e l y

s h o r t t i m e .

L eaver and Hardaway (1937) had a m o r t a l i t y

r a t e o f 7 1% w here t u b e d r a i n a g e was t h e s o l e t r e a t m e n t ,

w h i l e B ro ck (1943) had a m o r t a l i t y r a t e o f 91%,

The Committee o f t h e A m er ican S a n a t o r iu m

A s s o c i a t i o n ( 1 9 3 1 ) , i n t h e i r i n v e s t i g a t i o n i n t o t h e

m ethods a n d r e s u l t s o f d i f f e r e n t s a n a t o r i a i n t r e a t i n g

empyema r e p o r t e d a m o r t a l i t y r a t e o f 50% f o r c l o s e d

d r a i n a g e and 56% f o r c a s e s t r e a t e d b y open d r a i n a g e .

T h e re i s no d o u b t a b o u t t h e v e r y h i g h m o r t a l i t y

r a t e i n c a s e s o f empyema t r e a t e d by open o r c l o s e d

d r a i n a g e •

I n my s e r i e s , t h r e e p u re t u b e r c u l o u s empyemata

were d r a i n e d , b u t f i v e o t h e r c a s e s had a l r e a d y t h e i r

s e c o n d a r y i n f e c t i o n a t t h e t im e d r a i n a g e was s t a r t e d .

176

Of t u b e d r a i n a g e o f p u r e t u b e r c u l o u s empyema

A l e x a n d e r (1937) s a y s "Under no c o n d i t i o n t h a t I know

s h o u ld a p u re t u b e r c u l o u s empyema be d r a i n e d w i t h a

t u b e . " No one would d i s a g r e e w i t h t h i s . As

f a r a s t h e d r a i n a g e o f s e c o n d a r i l y i n f e c t e d c a s e s i s

c o n c e r n e d B ro ck (1943) c o n s i d e r s i t may do some good

p r o v i d e d t h o r a c o p l a s t y c a n be done i n a s s h o r t a t im e

a s p o s s i b l e a f t e r d r a i n a g e i s s t a r t e d .

I n t h i s s e r i e s o n l y two c a s e s were s u i t a b l e

f o r t h o r a c o p l a s t y a f t e r t u b e d r a i n a g e ; t h e s e w i l l be

c o n s i d e r e d u n d e r t h e h e a d in g T h o r a c o p l a s t y , a n d a r e

n o t i n c l u d e d i n t h e e i g h t p a t i e n t s m e n t io n e d a b o v e .

Ole o t h o r a x .

Twelve p a t i e n t s i n t h i s s e r i e s had o l e o t h o r a x .

T h re e came t o t h o r a c o p l a s t y . I n t h e n i n e p a t i e n t s

i n w h i c h o l e o t h o r a x was t h e f i n a l l i n e o f t r e a t m e n t ,

a r e i n c l u d e d t e n empyemata , i n t h a t one p a t i e n t had

b i l a t e r a l o l e o t h o r a x ahd empyema. Of t h e s e n i n e

p a t i e n t s f i v e a r e a l i v e ( i n c l u d i n g t h e p a t i e n t w i t h

b i l a t e r a l empyema) an d f o u r a r e d e a d .

Five p a t i e n t s were i n Group A and t h r e e o f

t h e s e a r e a l i v e , w h i l e tw o a r e d e a d . Four p a t i e n t s

were i n Group B. Two o f t h e s e c a s e s a r e a l i v e and

tw o a r e d e a d . D e t a i l s o f t h e d u r a t i o n and t y p e o f

o l e o t h o r a x u se d i n t h e n in e c a s e s so t r e a t e d a r e

177

g i v e n i n T a b le s.. 6^ and 65.

S u r v i v a l f rom o n s e t o f empyema i n t h e t h r e e

Group A p a t i e n t s s t i l l a l i v e i s , s o f a r , 7 y e a r s ,

8 y e a r s and 8 y e a r s . Of t h e tw o Group A p a t i e n t s

now d e a d , s u r v i v a l f rom o n s e t o f empyema was 8 y e a r s

and 2 months and 4 y e a r s r e s p e c t i v e l y .

I n t h e Group B c a s e s t h e tw o p a t i e n t s who

a r e a l i v e have s u r v i v e d 6-j- a n d 6 y e a r s r e s p e c t i v e l y .

T h i s l a t t e r p a t i e n t had b i l a t e r a l empyema a n d i s

s t i l l h a v in g o c c a s i o n a l a s p i r a t i o n s o f t h e r i g h t

empyema.

The two c a s e s i n Group 3 who a r e d e a d

s u r v i v e d 4 y e a r s and 1 y e a r and 2 months r e s p e c t i v e l y .

Two p a t i e n t s who were t r e a t e d by o l e o t h o r a x

had b r o n c h o - p l e u r a l f i s t u l a © , one b e f o r e o l e o t h o r a x

was i n s t i t u t e d and t h e o t h e r f o u r months a f t e r

o l e o t h o r a x was s t a r t e d .

Of t h e n in e c a s e s i n t h i s s e r i e s t r e a t e d by

o l e o t h o r a x , s i x g o t p l e u r o - c u t a n e o u s f i s t u l a e .

N e v e r t h e l e s s , f i v e ( 5 5 . 5 / 0 ' o f t h e t o t a l o f n in e p a t i e n t s

i n whom o l e o t h o r a x was t h e f i n a l fo rm o f t r e a t m e n t have

s u r v i v e d f a i r l y long p e r i o d s ( f rom 8 y e a r s t o 6 y e a r s )

s i n c e t h e o n s e t o f empyema.

W o o d ru f f (1938) found o l e o t h o r a x s eco n d t o

t h o r a c o p l a s t y i n t h e s u c c e s s f u l t r e a t m e n t o f t u b e r c u l o u s

178empyema. A le x a n d e r (1937) q u o t e s r e s u l t s o f d i f f e r e n t

w o r k e r s showing t h a t o f 127 c a s e s t r e a t e d by o l e o

t h o r a x , e i g h t y (63$ ) were s a t i s f a c t o r y and f o r t y - s e v e n

(37$) u n s a t i s f a c t o r y a f t e r a n o b s e r v a t i o n p e r i o d o f

s i x y e a r s •

l e a v e r and Hardaway (1937) made o l e o t h o r a x

t h e i r f i r s t c h o i c e i n t r e a t m e n t . I n t h i r t y - f i v e

c a s e s t h e y r e p o r t e d e i g h t e e n ( 5 1 .4 $ ) c u r e s . M atson

(1932) i n a n e x h a u s t i v e p a p e r on o l e o t h o r a x found

t h a t o f f i f t y c a s e s t r e a t e d by t h i s m e th o d , s a t i s

f a c t o r y r e s u l t s were o b t a i n e d i n t h i r t y ( 6 0 $ ) , w h i l e

t w e n t y (40$) were u n s a t i s f a c t o r y . Skavlem e t a l ( 1 9 4 0 ) ,

on t h e o t h e r h a n d , r e v i e w i n g f o r t y c a s e s r e p o r t e d

t h a t o n ly t h i r t e e n ( 3 2 .5 $ ) c o u ld be c l a s s e d a s " r e

c o v e r e d " and f o u r t e e n (35$) had d i e d .

Brow ning , Dundon and Ray (1941) i n a

r e p o r t on f o r t y - e i g h t c a s e s o f empyema9c o n c lu d e d

t h a t c a s e s i n whom a good p e rm a n e n t c o l l a p s e i s d e s i r e d

an d who a r e good s u r g i c a l r i s k s , s h o u l d have t h o r a

c o p l a s t y . A l l o t h e r s s h o u ld have o l e o t h o r a x .

These c o n c l u s i o n s were b a s e d on a " c u r e " r a t e o f

n e a r l y 70$ and a m o r t a l i t y o f o n ly 1 0 . 4 $ u s in g o l e o

t h o r a x a s t h e f i n a l fo rm o f t r e a t m e n t .

179

Hoffman an d K e t t l e r (1943) s t a t e t h a t i n

t h e i r o p i n i o n o l e o t h o r a x w i l l p o s tp o n e or e n t i r e l y

a v o i d s u b s e q u e n t t h o r a c o p l a s t y .

H e w l e t t q u o t e d by A le x a n d e r (1937) has

p o i n t e d ou t t h a t r e s u l t s w i t h o l e o t h o r a x t e n d t o

c o r r e s p o n d with , t h e g e n e r a l c o u r s e o f t h e t u b e r c u l o u s

d i s e a s e . W i th u n c o n t r o l l e d p a r e n c h y m a to u s d i s e a s e

o l e o t h o r a x i s , t h e r e f o r e , o f l i t t l e v a l u e .

Hayes (1941) h a s a d v o c a t e d t h e use o f

o l e o t h o r a x i n c a s e s o f t u b e r c u l o u s empyema c o m p l i c a t e d

b y u n e x p a n d a b le l u n g , w h i l e A l e x a n d e r (1937) c o n s i d e r s

o l e o t h o r a x i s i n d i c a t e d o n ly when c o n t i n u a t i o n o f

p u lm o n a ry c o l l a p s e i s d e s i r e d i n c a s e s i n w h i c h

t h e empyema has p r o d u c e d a n o b l i t e r a t i n g p l e u r i t i s .

T h o r a c o p l a s t y .

T h o r a c o p l a s t y was p e r fo r m e d i n n in e c a s e s .

Five were i n Group A and f o u r i n Group 3 . Seven

p a t i e n t s had t h o r a c o p l a s t y done i n t h e p r e s e n c e o f

m i n i m a l , and two i n t h e p r e s e n c e o f m o d e ra te c o n t r a

l a t e r a l d i s e a s e •

A l l f i v e Group A p a t i e n t s a r e a l i v e and

tw o o f t h e f o u r Group 3 c a s e s a r e a l i v e . One o f t h e

Group 3 c a s e s i s d e ad an d t h e o t h e r was l o s t s i g h t o f .

180

Thus s e v e n ou t o f n i n e c a s e s t r e a t e d by t h o r a c o p l a s t y

a r e a l i v e - a s u r v i v a l r a t e o f 7 7 . 7 $ - and a l l a r e

w e l l an d w o r k i n g .

D e t a i l s o f t h e p r e l i m i n a r y t r e a t m e n t and i t s

d u r a t i o n b e f o r e t h o r a c o p l a s t y a r e g i v e n i n T a b le 66 .

Only t h r e e c a s e s had t h o r a c o p l a s t y done w i t h i n s i x

weeks f rom t h e s t a r t o f o t h e r t r e a t m e n t , w h i l e one

c a s e had had t w e n t y months o f p r e v i o u s t r e a t m e n t w h ic h

i n c l u d e d c l o s e d d r a i n a g e .

S u r v i v a l o f t h e t h o r a c o p l a s t y c a s e s r a n g e s

f rom e i g h t y e a r s t o t h r e e y e a r s and n i n e months .from

the- o n s e t o f empyema and f rom se v e n and a h a l f t o

a l m o s t t h r e e y e a r s s i n c e t h e l a s t s t a g e o f t h o r a c o p l a s t y .

T hese f i g u r e s show t h a t o f t h e v a r i o u s t r e a t

m ents u s e d , t h o r a c o p l a s t y h a s g i v e n t h e b e s t r e s u l t s

w i t h n e a r l y 7 8 $ o f c a s e s r e c o v e r e d and a b l e t o w o r k .

F i g u r e s r e p o r t e d by o t h e r i n v e s t i g a t o r s

c o n f i r m t h e s e f i n d i n g s . Jones and A l e x a n d e r (1934)

r e p o r t e d 74$ o f c u r e s by t h o r a c o p l a s t y ; W o o d ru f f (1938)

7 9 $ , Skavlem e t a l (1940) 6 2 . 5 $ , B rock (1943) 95$ ,

Rose (1948) 7 3 $ .

A n d e r se n (1949) r e p o r t i n g on f i f t y - f i v e c a s e s

t r e a t e d by t h o r a c o p l a s t y found t h a t f o r t y - o n e ( 7 4 .5 $ )

were s a t i s f a c t o r y , two ( 3 .5 $ ) were u n im p ro v e d , an d

t w e l v e (22$) dead*

181

Of n i n e t e e n c a s e s t r e a t e d b y n o n - s u r g i c a l

m e t h o d s , o p l y one was c u r e d , one was im p ro v e d , and

f o u r t e e n (73 .7$)) w e r e - d e a d .

The r e a s o n f o r t h e s u c c e s s o f t h o r a c o p l a s t y

i s u n d o u b t e d l y t h a t b e s i d e s c l o s i n g t h e empyema s p a c e ,

c o n t r o l o f t h e u n d e r l y i n g lung d i s e a s e i s a c h i e v e d

s i m u l t a n e ous l y ,and a p p a r e n t l y more e f f i c i e n t l y t h a n

w i t h o t h e r fo rm s o f t r e a t m e n t .

U n f o r t u n a t e l y , however , s i n c e t u b e r c u l o u s

empyema o ccu rs c l a s s i c a l l y i n t h e p a t i e n t w i t h b i l a t e r a l

f i b r o e x u d a t iv e d i s e a s e , few p a t i e n t s a r e s u i t a b l e

f o r t h o r a c o p l a s t y .

O l e o t h o r a x and T h o r a c o p l a s t y .

I n com par ing t h e r e s u l t s o f t r e a t m e n t o f t u b e r

c u l o u s empyema by o l e o t h o r a x and b y t h o r a c o p l a s t y ,

t h e s u r v i v a l o f 5 5 . 6 $ o f t h e c a s e s t r e a t e d by o l e o t h o r a x

compared t o 7 7 . 8 $ f o r t h o r a c o p l a s t y , i s no t u n s a t i s

f a c t o r y . One o f t h e o l e o t h o r a x c a s e s had b i l a t e r a l

empyema, w i t h s e c o n d a r y i n f e c t i o n on t h e r i g h t s i d e .

I n t h i s s e r i e s , two p a t i e n t s who had o l e o

t h o r a x were p u t t o t h e s u r g e o n f o r c o n s i d e r a t i o n f o r

t h o r a c o p l a s t y b u t were t u r n e d down; t h e o t h e r s e v e n

c a s e s t r e a t e d by o l e o t h o r a x were n o t e v e n c o n s i d e r e d f o r

182

t h o r a c o p l a s t y . I n o t h e r w o r d s , o l e o t h o r a x c a n be

u s e d i n c a s e s w h i c h m ig h t be c o n s i d e r e d a t t h e s t a r t

w i l l n e v e r be s u i t a b l e f o r t h o r a c o p l a s t y . M o re o v e r ,

t h e b e t t e r r e s u l t s f o r t r e a t m e n t by t h o r a c o p l a s t y

a r e w e i g h t e d by t h e f a c t t h a t t h e s e c a s e s have h a d ,

f ro m t h e s t a r t , l e s i o n s t h a t were am enab le t o s u c c e s s

f u l t h o r a c o p l a s t y t r e a t m e n t . On t h e o t h e r h a n d ,

s e l e c t i o n o f c a s e s f o r t h o r a c o p l a s t y must be f a r more

e x c l u s i v e t h a n f o r o l e o t h o r a x .

A g a i n s t o l e b t h o r a x a s a method o f t r e a t m e n t

i s t h a t e v e n s u c c e s s f u l c a s e s c a r r y a r i s k o f c e r t a i n

l a t e c o m p l i c a t i o n s n o t e x p e r i e n c e d by t h o s e t r e a t e d

b y t h o r a c o p l a s t y s u c h a s b r o n c h o - p l e u r a l f i s t u l a , p l e u r o

c u t a n e o u s s i n u s e s and r e c u r r e n c e o f empyema.

One c a s e i n my s e r i e s g o t a b r o n c h o - p l e u r a l

f i s t u l a a n d s i x o f t h e t o t a l o f n i n e c a s e s g o t c h e s t

w a l l s i n u s e s . Skavlem e t a l (1940) c o n s i d e r e d

t h a t t h e i r method o f n o t c o m p l e t e l y f i l l i n g t h e p l e u r a l

sp a c e w i t h o i l a v o i d e d t h e s e c o m p l i c a t i o n s , b u t

t h i s h a s n o t b e e n c o n f i rm e d by o t h e r s .

O l e o t h o r a x has long b e e n abandoned i n t h e

C h e s h i r e J o i n t S a n a t o r i u m . I n s u i t a b l e c a s e s , t h o r a

c o p l a s t y o r p leu ro -pneum onechom y i s now t h e t r e a t m e n t

o f c h o i c e •

183

R e s u lt s o f V a r io u s Types o f T reatm ent

T a b le s 48: and 69 w ould s u g g e s t th a t th e

two im p o rta n t f a c t o r s f o r s u c c e s s f u l f i n a l trea tm en t

o f tu b e r c u lo u s empyema are -

1 . The a v o id a n c e o f seco n d a ry i n f e c t i o n ;

2. The c o n v e r s io n o f sputum.

Secondary I n f e c t io n o f Empyema

N e a r ly s i x t y - e i g h t p er c e n t o f th e t h i r t y -

fo u r s e c o n d a r ily in f e c t e d c a s e s a re d ead , compared

w ith a l i t t l e o v er f o r t y - f i v e per c e n t o f th e non

in f e c t e d Group A c a s e s .

Secondary i n f e c t i o n a r o se from bron ch o

p le u r a l f i s t u l a in e ig h te e n (5 1 .4 $ ) o f th e t h i r t y -

f i v e empyemata in Group B , w h ile f i f t e e n (4 2 .9 $ )

were in f e c t e d d u r in g tr e a tm e n t su ch a s a s p ir a t io n .

I t i s p e r m is s ib le to s u g g e s t th a t a lm ost

h a l f th e Group B c a s e s c o u ld have b een sp a red th e

co n seq u en c es o f a m ixed i n f e c t i o n by o b l i t e r a t i o n o f

th e p le u r a l sp a ce a t an e a r l i e r s ta g e . In o th e r w ords,

th e so o n er th e s e c o n d a r ily in f e c t e d c a s e can be g o t

read y f o r th o r a c o p la s ty , th e b e t t e r , i f th e c o n d it io n

o f th e c o n t r a - la t e r a l lu n g j u s t i f i e s th e r i s k . The

184

p l e u r a l sp a c e w i l l be o b l i t e r a t e d , t h e h o m o l a t e r a l

p u lm o n a ry d i s e a s e w i l l be b r o u g h t u n d e r c o n t r o l

w i t h p r o p o r t i o n a t e ' r e d u c t i o n i n t h e p e r i o d d u r i n g w h ic h

he i s e x p o s e d t o c o n t r a l a t e r a l s p r e a d an d t h e c o n s e q u e n c e s

o f c h r o n i c p y o g e n i c i n f e c t i o n .

R e g a rd in g o t h e r fo rm s o f t r e a t m e n t o f t h e

s e c o n d a r i l y i n f e c t e d c a s e . P e n i c i l l i n and t h e newer

a n t i b i o t i c s may a c h i e v e much i n t h e way o f e l i m i n a t i n g

o r r e d u c i n g s e c o n d a r y i n f e c t i o n a f t e r i t has o c c u r r e d ,

b u t t h e r e i s a lw a y s p r e s e n t t h e r i s k o f p e r s i s t e n t

n o n - s e n s i t i v e s t r a i n s ' o f o r g a n i s m r e m a i n i n g o r d e v e l o p

i n g .

A s p i r a t i o n e i t h e r a l o n e o r combined w i t h

l a v a g e o r t u b e d r a i n a g e a r e o f v e r y l i t t l e v a l u e .

T a b l e 48 shows t h a t o f t w e n t y - s i x p a t i e n t s t r e a t e d by

s u c h m e th o d s , o n ly t h r e e ( 1 1 .5 $ ) a r e a l i v e , and

t h e y a r e no t w e l l . Two o f t h e f o u r p a t i e n t s t r e a t e d

by o l e o t h o r a x a r e a l i v e , b u t t h e y a r e n o t w e l l and one

c a s e i s s t i l l h a v in g a s p i r a t i o n s 6 y e a r s a f t e r o n s e t o f

empyema.

C o n v e r s io n o f Sputum

T a b le 69 shows t h a t f i f t y - s i x p a t i e n t s were

d i s c h a r g e d f rom h o s p i t a l .

185

Of t h e t o t a l o f s e v e n t e e n d i s c h a r g e d

w i t h a p o s i t i v e s c u tu m , t h i r t e e n ( 7 6 .5 $ ) a r e d e a d ,

and o n l y f o u r ( 2 3 .5 $ ) a r e a l i v e .

On t h e o t h e r h a n d , o f t h i r t y - n i n e p a t i e n t s

d i s c h a r g e d w i t h e i t h e r no spu tum o r a n e g a t i v e sputum,"

t w e n t y - f i v e ( 6 4 .1 $ ) a r e a l i v e and f o u r t e e n ( 3 5 .9 $ )

a r e d e a d .

I t has b e e n o u r e x p e r i e n c e i n t h e C h e s h i r e

J o i n t S a n a t o r iu m t h a t p a t i e n t s d i s c h a r g e d w i t h a

p o s i t i v e spu tum and a r i s i n g b l o o d s e d i m e n t a t i o n

r a t e have t h e p o o r e s t p r o g n o s i s , and i t was hoped t o

a t t e m p t t o c o r r e l a t e len g th , o f s u r v i v a l a c c o r d i n g

t o spu tum a n d s e d i m e n t a t i o n r a t e a t d i s c h a r g e . T a b le 71

shows a t r e n d i n t h e d i r e c t i o n t h a t i n p a t i e n t s w i t h a

p o s i t i v e spu tum a t d i s c h a r g e , l e n g t h o f s u r v i v a l i s

r e l a t e d t o t h e r a p i d i t y or o t h e r w i s e o f t h e s e d i m e n t a t

i o n r a t e a t d i s c h a r g e , b u t T a b l e s 72 and 73 do no t

show t h a t t r e n d and seem t o b e a r o u t t h a t e i t h e r no

spu tum o r a n e g a t i v e spu tum i s more i m p o r t a n t t h a n a

r a p i d s e d i m e n t a t i o n r a t e a t d i s c h a r g e .

T r e a t m e n t o f Group A Cases

I n t r e a t m e n t o f Group A c a s e s , t h o r a c o p l a s t y

i s t h e most s u c c e s s f u l t r e a t m e n t , w i t h o l e o t h o r a x

a p p a r e n t l y t h e s eco n d b e s t . ^ s few c a s e s a r e s u i t a b l e

186f o r t h o r a c o p l a s t y and o l e o t h o r a x c a r r i e s t h e r i s k

o f l a t e c o m p l i c a t i o n s , one i s l e f t w i t h o n l y a s p i r a t i o n

( p l u s l a v a g e ) a s t h e a v a i l a b l e t r e a t m e n t .

I t seems f rom T a b le 48 t h a t one can hope

f o r a b o u t 50$ s u c c e s s w ith , t h e s e m ethods o f t r e a t m e n t ,

b u t b e f o r e s u c h t r e a t m e n t i s em barked upon i t must

be d e c i d e d w h e t h e r t h e c o l l a p s e d lu n g w i l l be w o r t h

r e - e x p a n d i n g l a t e r . T a b le 78 would s u g g e s t t h a t

t h e r i s k may be w o r t h w h i l e . On t h e o t h e r hand ,

one i s t a k i n g t h e a d d i t i o n a l r i s k o f t h e d a n g e r s o f

t r e a t i n g p r o l o n g e d empyema, a n d e v e n t h e r e - e x p a n d e d

l u n g s , i n t h e p r e s e n c e o f much d i s e a s e , a r e f r e q u e n t l y

p h y s i o l o g i c a l l y p o o r l u n g s . T a b le 78 shows t h a t o f

f i f t y - t h r e e c a s e s i n whom t h e c o l l a p s e was a b a n d o n e d ,

t h i r t y - t w o ( 6 0 .4 $ ) a r e d e a d , and o n ly s e v e n t e e n (32$)

a r e a l i v e , a g a i n s t 44$ dead and 48$ a l i v e i n c a s e s

i n w h i c h t h e c o l l a p s e was m a i n t a i n e d . I t would

a p p e a r , t h e r e f o r e , t h a t e a c h c a s e w ould have t o be

judged on i t s m e r i t s a s t o w h e t h e r c o l l a p s e s h o u ld be

m a i n t a i n e d or ab an d o n ed f o r t h w i t h on t h e o c c u r r e n c e

o f empyema.

I t i s u n f o r t u n a t e t h a t t h e t y p e o f c a se

i n w h i c h empyema i s most l i k e l y t o o c c u r and. i n t h e

e v e n t i s most common, s h o u ld f o r t h e same r e a s o n s be

t h e c a s e i n w h ic h a n y form o f s u r g e r y i s most h a z a r d o u s •

187

M o d i f i e d s u r g e r y ( i f i t c a n be so c a l l e d )

s u c h a s d e c o r t i c a t i o n o f t h e lu n g an d a t t e m p t t o

c l o s e t h e empyema s p a c e b y e x t r a - p e r i o s t e a l p o l y t h e n e

p a c k h a s b e e n a t t e m p t e d i n o u r S a n a t o r i u m , b u t has n o t

met w i t h s u c c e s s .

T h o r a c o p l a s t y , and l a t e l y p le u ro -p n e u m o n e c to m y

w here t h e lung i s v e r y p o o r p h y s i o l o g i c a l l y , a r e t h e

o n l y fo rms o f s u r g i c a l t r e a t m e n t now u s e d . B o t h

i n v o l v e d r a s t i c s u r g e r y , b u t o f f e r t h e c h i e f hope

o f s u c c e s s f u l t r e a t m e n t o f t u b e r c u l o u s empyema.

The n e e d , t h e r e f o r e , i s t o d i r e c t t r e a t m e n t t o r a i s i n g

t h e p r o p o r t i o n o f p a t i e n t s i n whom s u r g e r y would

become a p r a c t i c a l p o s s i b i l i t y .

S t r e p t o m y c i n , combined w i t h Para-amin©

s a l i c y l i c a c i d w i t h or w i t h o u t p h r e n i c c r u s h , - and

p n e u m o - p e r i t o n e u m a s a p r e l i m i n a r y t r e a t m e n t , m ight

by c o n t r o l l i n g c o n t r a l a t e r a l d i s e a s e i n c r e a s e t h e

number o f p a t i e n t s u l t i m a t e l y s u i t a b l e f o r t h o r a c o p l a s t y .

P ie u ro -p n e u m o n e c to m y i s p o s s i b l e o n ly i n t h o s e p a t i e n t s

i n whom t h e c o n t r a l a t e r a l lung i s shown by to m o g rap h y

t o be c o m p l e t e l y c l e a r o f d i s e a s e .

F i n a l l y , i t h a s t o be a d m i t t e d t h a t t h e r e

w i l l o c c u r c a s e s o f t u b e r c u l o u s empyema d u r i n g a r t i f i c i a l

p n eu m o th o ra x t r e a t m e n t , f o r w h i c h l i t t l e can be done

188o t h e r t h a n by s o - c a l l e d c o n s e r v a t i v e m e t h o d s , and

t h a t a t l e a s t h a l f t h e s e c a s e s a r e d e s t i n e d f o r an

e a r l y d e a t h .

189

SUMMARY AND CQUCLUSIQETS

The in c id e n c e o f tu b e r c u lo u s empyema in

a r t i f i c i a l pneum othorax i s rev iw ed .

The e t i o lo g y o f e ig h ty -o n e c a s e s o f pure

and p y o g e n ic a l ly in f e c t e d empyema in s e v e n t y - e ig h t

p a t ie n t s i s rev iew ed and d is c u s s e d .

The p r in c ip a l c a u se s o f empyema in t h i s

s e r i e s seem to have b e e n -

1. C hoice o f u n s u it a b le c a s e s f o r c o l la p s e

b y pneum othorax, e i t h e r b ec a u se o f th e ty p e o f

d is e a s e o r i t s a c u te a c t i v i t y a t th e tim e o f in d u c t io n

o f c o l la p s e .

2 . M aintenance o f u n s a t i s f a c t o r y , i n e f f e c t i v e

or d e - s e l e c t i v e c o l la p s e due to a d h e s io n s .

3. C onsequent f a i l u r e to a c h ie v e c a v i t y c lo s u r e

in a h ig h p e rc e n ta g e o f c a s e s , r e s u l t i n g in d e v e lo p

ment o f b r o n c h o -p le u r a l f i s t u l a e .

4 . A d h esion s e c t io n , e s p e c i a l l y e x t e n s iv e

c a u t e r iz a t io n o f a d h e s io n s and a d h e s io n s e c t io n in

th e p r e se n c e o f p l e u r i t i s and a c t iv e p le u r a l or

s u b -p le u r a l d i s e a s e .

5. M aintenance o f c o l la p s e a f t e r com p lete

a t e l e c t a s i s had o ccu rred .

190

A r e v i e w o f t r e a t m e n t an d s u r v i v a l o f

p a t i e n t s f o l l o w i n g v a r y i n g form s o f t r e a t m e n t i s p r e s e n t e d

The a v o i d a n c e f o r s u c c e s s f u l e l i m i n a t i o n o f

s e c o n d a r y p y o g e n i c i n f e c t i o n i s t h e f i r s t e s s e n t i a l

i n t r e a t m e n t .

S u r g i c a l t r e a t m e n t i n s u i t a b l e c a s e s i s

t h e t r e a t m e n t o f c h o i c e . I n c a s e s u n s u i t a b l e f o r

s u r g i c a l t r e a t m e n t t h e r e i s some e v i d e n c e t o s u g g e s t

t h a t m a i n t e n a n c e o f p n eu m o th o rax i s w o r t h a t t e m p t i n g

i n c a s e s c l a s s e d a s s a t i s f a c t o r i l y c o l l a p s e d a t o n s e t

o f empyema, .p rov ided spu tum c o n v e r s i o n h a s b ee n o b t a i n e d .

The r e s u l t s o f t r e a t m e n t would a l s o a p p e a r

t o show t h a t i n p u re t u b e r c u l o u s empyema, a s p i r a t i o n

and l a v a g e w i t h a n t i s e p t i c s a n a d y es e t c . o f f e r s no

a d v a n t a g e o v e r a s p i r a t i o n and a i r r e p l a c e m e n t a l o n e .

O l e o t h o r a x i s p rone t o c o m p l i c a t i o n s ,

e s p e c i a l l y t h e f o r m a t i o n o f c h e s t w a l l s i n u s e s . T h i s

may p r e v e n t t h o r a c o p l a s t y b e i n g done i n a c a s e o t h e r

w i s e s u i t a b l e f o r o p e r a t i o n .

P r e v e n t i o n o f Bimpyema .

The b e s t t r e a t m e n t f o r empyema i s t o p r e v e n t

i t . T h i s i n v o l v e s

1 . The c h o ic e o f more s u i t a b l e c a s e s f o r

t r e a t m e n t by p n e u m o th o ra x .

191

Pneum othorax should, n o t be in d u c e d i n :

1 . Cases o f a c u t e t u b e r c u l o u s c a s e o u s d i s e a s e .

Such c a s e s m igh t be t r e a t e d b y p n eu m o th o rax a f t e r a

c o u r s e o f s t r e p t o m y c i n an a p a r a - a m i n o s a l i c y l i c a c i d

w i t h o r w i t h o u t accom pany ing p h r e n i c c r u s h and pneumo

p e r i t o n e u m and p r e f e r a b l y a f t e r t h e s e d i m e n t a t i o n

r a t e h a s f a l l e n be low 40 m.m. i n 2 h o u r s ( W e s t e g r e n ) .

2 . Cases w i t h e x t e n s i v e d e s t r u c t i o n o f t i s s u e .

3 . Cases o f l a r g e a p i c a l c a v i t y .

4 . Cases o f m u l t i p l e c a v i t a t i o n .

5 . Cases o f e n d o - b r o n c h i a l t u b e r c u l o s i s .

These m ig h t have p r e l i m i n a r y t r e a t m e n t

w i t h s t r e p t o m y c i n and p a r a - a m i n o s a l i c y l i c a c i d an d

i f b r o n c h o s c o p y s h o u l d show c l e a r i n g and h e a l i n g o f

t h e l e s i o n s and no s e v e r e d e g r e e o f b r o n c h p - s t e n o s i s

p n e u m o th o ra x m ig h t be a t t e m p t e d .

W hile a n a d e q u a t e p e r i o d o f bed r e s t i s

p e r h a p s d e s i r a b l e b e f o r e i n d u c t i o n o f p n e u m o th o ra x ,

t h e need f o r r a p i d bed t u r n o v e r a t t h e p r e s e n t t im e

p r e c l u d e s t h i s c o u r s e . P h r e n ic c r u s h and pneumo

p e r i t o n e u m w i l l a c h i e v e t h e same end i n a s h o r t e r t i m e .

P neum othorax s h o u ld be ab an d o n ed i n : -__

1 . Cases o f d e - s e l e c t i v e , i n c o m p l e t e and i n

e f f e c t i v e c o l l a p s e , i n c l u d i n g t h o s e r e q u i r i n g p o s i t i v e

192

i n t r a - p l e u r a l p r e s s u r e s t o m a i n t a i n t h e c o l l a p s e .

2 . Cases w i t h m u l t i p l e a d h e s i o n s w h ic h would

i n v o l v e e x t e n s i v e c a u t e r i z a t i o n .

3 . Cases i n w h i c h p l e u r i t i s and t u b e r c u l o u s

p l e u r a e a r e found a t t h o r a c o s c o p y .

4 . Cases w h i c h d e v e l o p s u f f i c i e n t f l u i d b e f o r e

a d h e s i o n s e c t i o n a s t o r e q u i r e a s p i r a t i o n .

5 . Cases i n w h ic h t h e c o l l a p s e i s n o t s u c c e e d

i n g i n c l o s i n g a c a v i t y o r c a v i t i e s e v e n a l t h o u g h

t h e c o l l a p s e i s a n a t o m i c a l l y and r a d i o l o g i c a l l y s a t i s -

f a c t o r y .

6 . Cases i n w h i c h co m p le te a t e l e c t a s i s o c c u r s

e v e n i f c o m p le te a e r a t i o n f o l l o w s b r o n c h o s c o p y i n a

s h o r t t im e and ev en a l t h o u g h t h e c o l l a p s e a p p e a r s

t o be s a t i s f a c t o r y .

193

BIBLIOGRAPHY

A le x a n d e r ,J . (1 9 3 ? ) . The C o lla p s e T reatm ent o f Pulm onary T u b e r c u lo s is . . B a i l l i e r e , T in d a l and Cox, London.

A nderson ,R . S. , and A le x a n d e r ,J . I b id .

A n d ersen , D.A. , (1 9 4 9 ) . B r it .M ed . Journ . 2; 6.

B a r n w e ll, J . B . , L i t t i g , J . , and C u lp ,J .E . (1 9 3 7 ) .Amer. Rev. Tub e r e . 36; 8.

B enjam in , P. V . , (1937) In d . Med. Gaz. 72; 212.

B r a n t ig a n ,0 . 0. , H o ffm a n ,R ., and P r o c to r , D. P. (1 9 4 2 ) . Amer. Rev. T uberc. 45; 477 .

B rock , B. L. , M u llen , A .B . , and Woodson, T. A. (1 9 3 7 ) . Amer. Rev. T uberc. 35; 548.

B ro ck , R. C. (1 9 3 8 ) Brompt. Hosp. R ep orts 7; 81 .(1 9 4 3 ) B r it .J o u r n . Tuberc. 37; 18.

B row ning, R. H. , Dundon, C. C. , and Ray, E. S. (1 9 4 1 ) .Amer. Rev. T uberc. 43; 319.

C h an d ler , P. G .,(1 9 3 7 ) T u b erc le 18; 298.(1942) B r i t . Journ . Tuberc. 36; 103

C o e l lo , A . J . , (1937) T u b erc le 28; 136

C o r y l lo s , P .N . , (1933) A m er.R ev.Tuberc. 28; 1.(1937; Journ. Thor. Surg. 7; 48

Com mittee R eport Amer. San. A s so c .o n 'T r e a t . Emp. ,(1 9 3 1 ) Amer. Rev. Tuberc. 24; 757.

C u th b er t, J . and H agley,M .H . ,(1 9 4 8 ) T u b erc le 29; 154.

C u t le r , I .L . , ( 1 9 4 1 ) . A m er.R ev.T uberc. 43; 197.

D a v id so n , L . R . , ( 1 9 4 1 ) .Q u a r t.B u ll. Sea View Hosp. 6; 382.

D a v ie s , H. M o r r is to n ,(1933) Pulmonary T u b e r c u lo s is , London.

194

De C e c i o , T . and P o t t e r B . P . ( 1 9 3 9 . ) Amer. R ev . T u b e r c .4 0 ; 2 7 2 .

D ic k e y A .B . ( 1 9 4 3 ) ; Amer. R ev . T u b e r c . 48 ; 2 2 2 .

D u b o f f W.S. ( 1 9 1 9 ) . Amer. R ev . T u b e r c . 10 ; 5 9 0 .

E d w a rd s , P . W. and Lynn A. ( 1 9 3 9 ) ; B r i t . Med. J o u r n .2 ; .287.

E l o e s s e r L. ( 1 9 3 4 ) . Amer. Rev. T u b e r c . 3 0 ; 123 .

T?i s h b e r g , M. ( 1 9 3 2 ) ; Pu lm onary T u b e r c u l o s i s V o l . 2 .(H. K im pton , L o n d o n ) .

G l o y n e , S . R. ( 1 9 2 6 ) , T u b e r c l e 7 ; 4 2 4 .

(4dor w itc h J • 1943 ) , Amer . Rev . lu b e r c . 47; 3 9 4 .

G ordon B . , C h a r r R . , and Sava cod J.W. ( 1 9 4 3 ) ; Amer.R ev . T u b e r c . 47 ; 3 5 .

Hayes J . N. ( 1 9 2 7 ) ; Amer. Rev . T u b e r c . 16; 680 .( 1 9 4 1 ) ; J o u r n . T h o r a c i c S u r g . 10; 603 .

H e a f P . and Rusby N. L. ( 1 9 4 8 ) ; R ec en t Advances i n R e s p . T u b e r c . ( C h u r c h i l l , London) .

Hoffman R. an d K e t t l e r M. ( 1 9 4 3 ) ; Ame r . Rev . T u b e r c . 4 7 ; 3 8 8 .

Hoyle C. ( 1 9 4 3 ) ; B r i t . J o u r n . T u b e r c . 3 7 ; 10.

J a c o b e u s H.C. ( 1 9 2 2 ) ; Amer. Rev . T u b . 6; 8 7 1 .(1 9 2 3 ) ; P r o c . Roy. S o c . Med. 16; 9 .

J o n es J . C. and A l e x a n d e r J . ( 1 9 3 4 ) ; Amer. Rev.T u b e r c . 2 9 ; 2 3 0 .

K eers R. Y. & R ig d e n B. G. (1 9 4 5 ) ; Pulmonary T u b e r c u l o s i s . ( L i v i n g s t o n e , E d i n b u r g h ) .

K e n t , E . M. ( 1 9 4 2 ) ; Amer. Rev. T u b e r c . 47; 5 2 4 .

K o r o l S . M. ( 1 9 3 6 ) ; R a d i o l o g y 3 6; 5 .

195

L e a v e r P. Y. and Hardaway R . M. ( 1 9 3 7 ) ; Amer. Rev . T u b e r c . 3 5 ; 5 3 8 .

L i l i e n t h a l H. ( 1 9 2 5 ) . T h o r a c . S u r g . V o l . 2 .(”r . 3 . S a u n d e r s C o . , P h i l a d e l p h i a ) .

Maher-Loughman G. P. ( 1 9 5 0 ) ; T u b e r c l e 3 1 ; 74 and 9 8 .

Matson R. V. ( 1 9 3 2 ) ; Amer. Rev . T u b e r c . 25 ; 41 9 .

M atson R. W., Matson R. C. and B i s a i l l o n M. ( 1 9 2 4 ) ; T u b e r c l e 5 ; 3 2 5 .

M a t t i l l P . M. an d J e n n in g s P. L. ( 1 9 4 0 ) ; Amer. Rev. T u b . 41 ; 3 8 .

M o r r i s b h , J * B. ( 1 9 4 8 ) ; Amer. Rev. T u b . 57 ; 5 9 8 .

Munro-Ashman and T a t e M. G. ( 1 9 4 3 ) ; T u b e r c l e 2 4 ; 181 .

N i c k l a s J . M., P r a n k l i n R. M. and Zavod W. A. ( 1 9 3 7 ) ; .-Amer. Rev. T u b e r c . 3 6 ; 437 .

Orn&teifP- 0 . 0 . & TJlmar D. ( 1 9 3 9 ) ; Q u a r t B u l l SeaviewH osp . 4; 2 69 .

P a c k a r d , 3 . W., Hayes J . M., B l a n c h e t S . P. ( 1 9 4 0 ) ; A r t i f i c i a l P neum othorax . P h i l a d e l p h i a .

P a u l s o n , D. N. and Shaw R. R. ( 1 9 4 9 ) ; J o u r n . T h o r . S u r g . 18; 7 4 7 .

P a q u e t t e J . P . ( 1 9 4 6 ) ; Union Med du Canada 75 ; 1412 .

P e n i n g t o n A. H. ( 1 9 3 9 ) ; B r i t . J o u r n . T u b e r c . 3 3 ; 3 6 .

P e t e r s A. and Boo l e y J . S . ( 1 9 2 2 ) ; Amer. Rev . T u b e r c . 6 ; 6 5 9 .

P e t r o f f S . A . , Hermon M. and Pa l i t z L. ( 1 9 4 1 ) ;Amer. Rev . T u b e r c . 44; 7 3 8 .

P i n n e r M. ( 1 9 4 4 ) ; Pu lm onary T u b e r c u l o s i s i n t h e A d u l t . (C. C. Thomas, S p r i n g f i e l d , I l l i n o i s ) .

R a f f e r t y T . N. ( 1 9 4 3 ) ; J o u r n . T h o r a c . S u r g . 12; 5 7 8 .( 1 9 4 4 ) ; A r t i f i c i a l Pneumothorax i n

Pu lm onary T u b e r c u l o s i s .(rrm. He i ne ma n n , Lond o n ) .

196

Rose P . ( 1 9 4 8 ) ; Schweiz Z e i t P. T u b e r k . 5 ; 2 61 .

R o s e n t h a l D. B. ( 1 9 3 6 ) ; B r i t . Med. J o u r n . 1; 9 5 .

S a l k i n D. & Cadden A. V. ( 1 9 4 1 ) ; J o u r n . T h o r a c . S u r g . 11; 12 6 .

Sampson P . N. ( 1 9 3 7 ) ; J o u r n . T h o r a c . S u r g . 6; 197.

S h i e l d s D. 0 . ( 1 9 4 4 ) ; Amer. Rev. T u b e r c . 5 0 ; 122 .

Shipman S . J . ( 1 9 4 2 ) , Amer . Rev . T u b e r c . 45; 3 6 4 .

Simmonds P. A. H. ( 1 9 4 1 ) , T u b e r c l e 2 2 ; 183.

Skavlem J - F . , P h e lp s M. M., Baker L. 8 . and C h r i s t i a n s e n J . N. ( 1 9 4 0 ) ; Amer. Rev. T u b e r c . 42;

S t o b i e W. ( 1 9 3 0 ) ; T u b e r c l e 11; 2 5 3 .

V i s w a n a th a n R. (1 9 4 9 ) : D i s e a s e s o f Ches t 15; 460 .

Weisman J . I . ( 1 9 3 6 ) ; Amer. Rev. T u b e r c . 3 3 ; 5 2 2 .

W o l l a s t o n P. L. ( 1 9 4 0 ) ; B r i t . J o u r n . T u b e r c . 3 4 ;

W o l l a s t o n P. L. a n a Landau N. ( 1 9 4 6 ) ; T u b e r c l e 26

X a l a b a r d e r C. ( 1 9 4 9 ) ; T u b e r c l e 3 0 ; 2 6 6 .

7 4 7 .

.t J «

43 .

Date post:	21-Jan-2021
Category:	Documents
Upload:	others
View:	0 times
Download:	0 times

TUBERCULOUS EMPYEMA in ARTIFICIAL PNEUMOTHORAX … · 2020. 3. 10. · Thesis are, therefore, very...

Documents